Bleeding in Early Pregnancy

Bleeding in Early Pregnancy

Ectopic Pregnancy

An ectopic or extrauterine pregnancy is one in which the blastocyst implants anywhere other than the endometrial lining of the uterine cavity. The incidence is approximately 1 in 300 normal pregnancies worldwide.

Sites of Ectopic Pregnancy

• The most common location of ectopic pregnancies is an oviduct. The most common location within the oviduct is the fallopian tube 95-99%, most frequently in distal ampulla.
• Ovarian 0.5%
• Abdominal 0.1%

Risk Factors

• Previous pelvic inflammatory diseases
• Genital tuberculosis
• Endometriosis in the pelvis causing distortion of the fallopian tube
• Previous ectopic pregnancy
• Pelvic adhesions
• Congenital elongation, accessory ostia, diverticula
• Transmigration
• Previous tubal surgery, tubectomy
• In Vitro Fertilization (IVF)
• Intra uterine contraceptive device (IUCD), progesterone containing IUCD
• Progestogen-only pills (POP)
• If the patient has had one ectopic pregnancy, the incidence becomes 15%

Mode of Termination

Once implanted, the pregnancy may get along one of several pathway leading to various presentation in patient.

Tubal Abortion

Most frequently, implantation takes place in the ampulla, although rupture typically happens in the isthmus. When there is a choriodecidual hemorrhage, the ovum becomes dislodged and is discharged into the tubal lumen. If the placenta entirely detached, all tissues would have protruded into the pelvic cavity. In most cases, it causes a complete abortion; if not, the endosalpinx-attached fetus will bleed. Some bleeding persists and forms a hematosalpinx in the oviduct. Carneous mole is the result, which is the same as a missed abortion.

Tubal Rupture

The tubal rupture is more frequent when the fertilized ovum implants in the isthmus or interstitial region of the tube. The oviduct can be torn open at any point by the encroaching, growing products of conception. Although it can happen early in the first trimester, interstitial pregnancy generally happens later. Normal spontaneous tube rupture may result in shock. The patient may be bleeding heavily and continuously.

Tubal Mole

Repeated bleeding causes blood clots to develop in the tube, separating the villi from their attachment, and causing a tubal abortion, which expels the mole via the abdominal ostium. Due to internal bleeding, the mole developed into a pelvic haematocele.

Clinical Findings

Symptoms

• The classic triad with an unruptured ectopic pregnancy is amenorrhea, vaginal bleeding, and unilateral pelvic-abdominal pain.
• With a ruptured ectopic pregnancy, the symptoms will vary with the extent of intra peritonealbleeding and irritation.
• Pain usually occurs after 6-8 menstrual weeks.

Signs

• Unilateral adnexal and cervical motion discomfort are the typical signs of an unruptured ectopic pregnancy.
• Fever and uterine hypertrophy are typically absent.
• The results show the degree of hypovolemia and peritoneal irritation in an ectopic pregnancy that has burst.
• Significant blood loss is indicated by tachycardia and hypotension.
• This causes stiffness and abdominal guarding.

Investigation

• A complete blood count that includes hemoglobin, blood group matching, and
• Adnexal mass may or may not be observed on ultrasound, but more importantly, no intrauterine pregnancy (IUP) will be detected.
• Tests for B-hCG will come out positive. 1,500 ml of B-hCG titer Only 50–60% of ectopic pregnancies are confirmed by urine pregnancy tests. More sensitive methods for detecting B-hCG in the serum include ELISA and radioimmunoassay, which can identify extremely early pregnancies up to 10 days before the missed period. Ultrasonography is advised if the test is positive.
• Laproscopy
• Uterine curettage
• Serum progesterone.

Management

Ruptured ectopic

• The diagnosis of ruptured ectopic pregnancy is presumed with a history of amenorrhea, vaginal bleeding, and abdominal pain in the presence of a hemodynamically unstable patient 
• Immediate surgical intervention to stop the bleeding is vital, usually by laparotomy.

Intrauterine pregnancy

• If the sonogram reveals the diagnosis is hydatidiform mole, the patient should be treated with a suction curettage and followed up on a weekly basis with B-hCG.

Unruptured ectopic

• Management can be medical with methotrexate or surgical with laparoscopy.
• Medical treatment is preferable because of the lower cost, with otherwise similar outcomes.

Methotrexate

• This folate antagonist attacks rapidly proliferating tissues including trophoblastic villi. Criteria for methotrexate include pregnancy mass <3.5 cm diameter, absence of fetal heart motion, B-hCG level <6,000 mIU, and no history of folic supplementation. Single dose 1 mg/kg is 90% successful.

Recurrent ectopic pregnancies:

• Follow-up with serial B-hCG levels is crucial to ensure pregnancy resolution.
• Rh-negative women should be administered RhoGAM (a medicine used to prevent Rh isoimmunization in mother who are Rh negative).
• Laparoscopy, if criteria for methotrexate are not met, surgical evaluation is performed through a
• Either by laparoscopy or a laparotomy incision. An unruptured ampullary tubal pregnancy is best treated with a salpingostomy, which preserves the oviduct by dissecting the trophoblastic villi free.
• Segmental excision, in which the tubal segment carrying the pregnancy is removed, is the treatment option for isthmic tubal pregnancies. Salpingectomy is only performed on patients who have burst ectopic pregnancies or who do not want to become pregnant again.
• To ensure that the pregnancy has ended after a salpingostomy, B-hCG titers should be acquired on a weekly basis. RhoGAM should be given to women who are Rh-negative.
• Patients who have received methotrexate or a salpingostomy should be monitored with B-hCG titers to ensure that the ectopic trophoblastic villi have been completely destroyed.

Gestational Trophoblastic Disease/ Hydatidiform Moles

The placenta exhibits aberrant changes in histology in abnormal pregnancies like hydatidiform moles, gestational trophoblastic disease, and molar pregnancy. The chorionic villi in these placentas typically exhibit trophoblastic proliferation and edema of the villous stroma in varying degrees. It might be benign or cancerous.

Classification

• Benign GTN is the Classic Hydatidiform Mole (H-mole). Incidence is 1:1200 in the US, but 1:120 in the Far East. Based on the degree and extent of the tissue changes, hydatidiform moles are categorized as either complete hydatidiform moles or partial hydatidiform moles
  • Complete mole is the most common benign GTN. It results from fertilization of an empty egg with a single X sperm resulting in paternally derived (androgenetic) normal 46, XX karyotype. No fetus, umbilical cord or amniotic fluid is seen. The uterus is filled with grape like vesicles composed of edematous avascular villi. Progression to malignancy is 20%.
  • Incomplete mole/ Partial mole is the less common benign GTN. It results from fertilization of a normal egg with two sperm resulting in triploid 69, XXY karyotype. A fetus, umbilical cord and amniotic fluid is seen which results ultimately in fetal demise. Progression to malignancy is 10%.
• Malignant GTN is the Gestational Trophoblastic Tumor (GTT) which can develop in 3 categories
  • Non-metastatic disease is localized only to the uterus.
  • Chest X-ray to rule out lung metastasis being the pelvis or lung. Cure rate is >95%
  • Poor Prognosis metastatic disease has distant metastasis with the most common locat being the brain or the liver. Other poor prognosis factors are serum b-hCG levels >40,000 4 months from the antecedent pregnancy, and following a term pregnancy. Cure rate is 65

Risk Factors

• Pregnancy in teenagers and elderly primigravida is most common.
• Poor nutrition inadequate protein consumption, folic acid and beta-carotene deficiency
• Impaired immune system
• Anomalies of the genome and genes.
• Previous history of hydatidiform mole.
• The risk increases with the number of spontaneous abortions.
• Women with blood type A may be more likely to develop choriocarcinoma.
• Oral contraceptives for more than 5years.
• H / O infertility.

Pathophysiology

Death of ovum or failure of embryo cause develop of complete hydatidiform mole. The secretion from the hyperplastic cells and transferred. The substance from the maternal blood accumulate in the stroma of the villi which are empty or free of blood vessels which results in distension of the vill form small vessels. The vesicle fluid is interstitial fluid and is almost similar to edema fluid but rich is HCG Hemorrhage occurs from decidual space and ovarian changes sur interal laten cysts present due to excessive production of chorionic gonadotropin hormone

Clinical Findings

• 8–12 week amenorrhea
• Prior to 16 weeks of pregnancy, bleeding may occur, as well as the passage of vesicles from the vagina. This brownish, watery discharge may be caused by a ruptured cyst.
• Oedema, hypertension, and/or proteinuria are some additional signs of a molar pregnancy.
• Pregnancy hyperemesis and hyperthyroidism
• No fetal heartbeat or movement was felt.
• The most typical symptoms are a fundus bigger than a date, the lack of fetal heart tones, and bilateral theca-lutein cysts, which are ovarian cystic enlargements.
• On vaginal examination, there was no internal ballotment felt.
• In vaginal discharge, vesicles or blood clots may be present.

Investigation

• Doppler: The auscultation of fetal heart by Doppler can rule out a complete molar pregnancy The absence of a fetal heart goes in favour of a molar pregnancy.
• Complete blood count, ABO and Rh grouping
• Hepatic, renal and thyroid function test Serum b-hCG level is very high in a complete mole, but is not very much raised in a partial mole
• A serum level of more than 40,000 mIU/ml..
• X-ray abdomen after 16 weeks pregnancy
• CT & MRI
• Ultrasound Ultrasound examination shows the 'snow storm appearance in the uterus and the absence of fetal shadow in a complete molar pregnancy. In a partial mole, the fetus (malformed or intrauterine growth retardation (IUGR)) and placenta are visualized.

Complications

• Hyperemesis gravidarum,
• Pregnancy-induced hypertension.
• Haemorrhage.
• Anemia
• Infection
• Thyroid storm-3%.
• Embolization with acute pulmonary insufficiency and
• Coagulation failure-2%
• Uterine perforation spontaneous but more commonly during suction evacuation.
• Delayed-recurrent mole and choriocarcinoma.

Management

• Prepare If blood transfusion is necessary, put up an intravenous oxytocin drip of at least 10-20 units in 500 mL of 5% glucose.
• To remove the uterine contents, use suction curettage. Methergine 0.2 mg administered intravenously can help with the evacuation.
• For the duration of the follow-up period, place the patient on an effective oral contraceptive pill to prevent any confusion between rising b-hCG titers from recurrent disease and typical pregnancy.
• Benign GTN: Weekly serial b-hCG titers for 3 weeks until they are negative, then monthly titers for 12 months until they are negative. The search for metastases is ongoing and includes ultrasonography and CT scans of the pelvis, abdomen, chest, brain, and other relevant areas.
• For non-metastatic or metastatic illness with a good prognosis, provide methotrexate or actinomycin D. Single agent (until weekly b-hCG titers are negative for 3 weeks), followed by monthly titers until they are negative for 12 months.
• For metastatic diseases with a poor prognosis: After evacuating a molar pregnancy, patients receive multiple agent chemotherapy (methotrexate, actinomycin-D, and cytoxan) until weekly b-hCG titers become negative for 3 weeks; typically, the test turns negative in 6–8 weeks. Then, patients receive monthly titers for 2 years, followed by every three months for another 3 years. The next step is for 5 years.

Cervical Ectropion (cervical erosion) /Erosion of Cervix

When a zone of columnar epithelium replaces the typical stratified squamous epithelium that is typically seen outside the external os on the vaginal section of the cervix, this condition is known as cervical ectropion. The blood vessels close below the surface give the exposed columnar epithelium a reddish appearance.

The erosion is the replacement of the squamous epithelium that covers the portiovaginalis of the cervix beyond the external cervical os without dermal penetration manifesting redness.

Definition

Cervical erosion is a common condition brought on by the presence of glandular cells, also known as soft cells, on the exterior of the cervix.

Hormonal changes, pregnancy, and usage of the pill can all result in cervical ectropion. It has no connection to the emergence of cervical cancer or any other condition that fuels the growth of cancer.

Sign and Symptoms

For the majority of women, cervical ectropion does not cause any problems and it usually goes away by itself without needing any treatment.

• Because soft cells bleed more easily and can create more mucus than hard cells, there is now more vaginal discharge than previously.
• Discomfort or bleeding from the vagina during or after intercourse. Pain may occasionally occur both during and after cervical screening.
• Cervical ectropion has been linked to Chlamydia trachomatis infection, human immunodeficiency virus (HIV) infection in female partners of HIV-positive males, and human papillomavirus.

Investigation

• Colposcopy is a method of assessment of the cervix.
• Biopsies to rule out carcinoma is essential Pap smear test
• STD HIV/AIDS (vaginal discharge should be examined).

Treatment

It is usually given at a colposcopy clinic and will be done using heat/cautery, which hardens the soft cells to stop them from bleeding.

The 2 different treatment options are listed below:

• Silver nitrate to cauterise/burn off the soft cells
• Cold coagulation which uses heat to cauterise/burn off the soft cells

Both treatments can result in some bleeding or discharge, as well as some 'period-like' pain. Sexual contacts require examination and treatment, and all involved individuals require reevaluation following treatment.

Cervical Polyps

Small, elongated tumors called cervical polyps develop on the cervix. The uterus's tiny opening that leads into the vagina is known as the cervix. One in 1,000 cervical polyps develop into cancer. Women who are perimenopausal or postmenopausal are more likely to develop cancer. There might be one or several polyps.

Polyps are tiny, often benign growths that develop from stalks anchored in the cervical canal or on the cervix's surface.

Causes of Cervical Polyps

• Infection
• An abnormal local response to increased levels of estrogen
• Chronic inflammation of the cervix, vagina, or uterus
• Clogged blood vessels
• Local congestion of the cervical vasculature
• They are most common in multiparous women.
• Polyps can appear anywhere but are most common on the cervix and in the uterus.
• Cervical polyps often appear after menarche. They occur in 2% to 5% of women, and approximately 2% of these polyps have cancerous changes.
• Endocervical polyps are commonly found in multiparous women ages 40 to 60.

Sign and Symptoms

• They are present in up to 25% of women being seen for abnormal bleeding,
• Most endocervical polyps are cherry red, whereas most cervical polyps are grayish-white vascular, protruding growth in the cervix.

Vaginal spotting or bleeding:

• after sexual intercourse
• after douching
• after menopause
• Between periods

Some of these symptoms can also be signs of cancer. In rare cases, polyps represent an early phase of cervical cancer. Removing them helps reduce this risk.

Treatment

• Remove vaginally with dilatation and curettage, hysteroscopy, or excision with tiny forceps performed as an outpatient procedure (D & C). By vaporizing it using a laser, it may be eliminated.
• After removing cervical polyps, treat with an antibiotic as an infection may develop.
• Sending the collected polyp samples for the cervical biopsy to the lab reveals slightly abnormal cells and indications of infection.
• Malignancy should be checked for using a Pap smear.

Abortion

The term "abortion" refers to the natural or artificial termination of a pregnancy before fetal viability, which is defined as before 22 weeks of gestation or when the fetus weighs less than 500 g.

Organizations do not always agree on the gestational period or fetal weight thresholds for abortion. According to the World Health Organization, an abortion is any pregnancy termination that occurs naturally or artificially before 20 weeks of pregnancy or when a fetus is born weighing 500 g. These requirements seem to contradict each other somewhat because the average weight of a normally developed 20-week fetus is 320 g while the average birth weight for 22 to 23 weeks is 500 g.

Classification of Abortion

Spontaneous

• Threatened abortion
• Complete abortion
• Missed abortion
• Inevitable abortion
• Incomplete abortion

Induced abortion

• Legal
• Septic abortion
• Recurrent abortion
• Illegal

Spontaneous Abortion

A spontaneous abortion refers to the loss of a fetus resulting from natural causes- that is, not elective or therapeutically induced by a procedure before fetal viability (22 weeks gestation).

Etiology

• Fetal genetic abnormalities
• Chromosomal abnormalities are more likely causes in the first trimester and maternal disease is more likely in the second trimester.
• The second trimester more likely related to maternal conditions, such as
  • Cervical insufficiency
  • Congenital or acquired anomaly of the uterine cavity (uterine septum or fibroids)
  • Dypothyroidism
  • Diabetes mellitus
  • Chronic nephritis
  • Use of crack cocaine
  • Inherited and acquired thrombophilias
  • Lupus, polycystic ovary syndrome
  • Severe hypertension and acute
  • Infection such as rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis, and toxoplasmosis.

Threatened abortion

Threatened abortion is the vaginal bleeding takes place in a pregnant woman during the first 22

weeks of pregnancy. The pregnancy may continue in threatened abortion.

Sign and symptoms

• Backache
• Bleeding is fresh and scanty
• Slight abdominal pain, but the membranes remain intact
• Cervical os is seen to be closed.

Treatment is usually not necessary.

Complete bed rest till bleeding stops.

• Abstinence is to be advice.
• Advise the woman to avoid vigorous work, squatting position and carry heavy loads. Regular antenatal checkup and assess for bleeding, Hb and haematinics, laxatives and sedatives if required.
• If bleeding continues, ultrasonography to assess for fetal viability.
• Do not give medications such as hormones (e.g. oestrogens or progestins) or tocolytic agents (e.g. salbutamol or indomethacin), as they will not prevent miscarriage.

Inevitable abortion

In this abortion the process of abortion has begun and progressed to such extent that expulsion of product of conception seems inevitable. In this abortion continuation of pregnancy is impossible.

Sign and symptoms

• Heavy vaginal bleeding that includes the passage of clots, new blood, and fetal tissue
• Due of the mother's extensive vaginal bleeding, she could be in shock
• Abdominal pain that is as severe as that experienced during labor as a result of uterine contractions
• Cervix dilated, membrane ruptured, and smaller-than-expected uterus

Management

• Start IV fluid and blood if patient needs to resuscitates for shock.
• Suction the remaining product of conception in aseptic strictly as soon as possible If pregnancy is less than 16 weeks.
• Give ergometrine 0.2 mg IM (repeated after 15 minutes if necessary) OR misoprostol 400 mcg by mouth (repeated once after four hours if necessary);
• Wait for spontaneous expulsion of products of conception and then evacuate the uterus to remove any remaining products of conception. Infuse oxytocin 40 units in 1 L IV fluids (normal saline or Ringer's lactate) at 40 drops per minute to help achieve expulsion of products of conception.
• Give tetanus and anti-D for Rh- negative mother.
• Give analgesic for acute pain.

Complete Abortion

In complete abortion, all the products of conception embryo/fetus, placenta and membranes are expelled completely from the uterus. This is more likely to occur in the first eight weeks of pregnancy.

Sign and symptoms

• Less pain and bleeding after expulsion of conceptus.
• Uterus firm, well contracted on palpation and smaller than the period of gestation.
• Ultrasonography shows empty cavity.
• Cervical os is closed.

Treatment

• No further medical intervention is required. Reassess the complete abortion, confirm by ultrasound examination.
• Advise the woman to revisit if bleeding recurs and if temperature develop.
• Tetanus toxoid.
• Anti- D for Rh- negative.
• Hematinics if blood was significant. Counsel the woman about family planning method and help to select the appropriate method.

Incomplete abortion

The expulsion of some but not all of the products of conception during 1" half of pregnancy is incomplete abortion. The fetus & placenta may remain entirely in utero or may partially extrude through the dilated os. This is more likely to occur in the second trimester of pregnancy.

Sign and Symptoms

• Despite the agony potentially ending, significant bleeding frequently occurs.
• The internal cervical os is still open and permits for the flow of blood and bodily waste.
• Lower abdomen ache that is colicky.

Management

• Retain tissue should be removed right away.
• If you are less than 16 weeks pregnant and your bleeding is light to moderate, you should use finger or sponge forceps to remove the fetus, and if it is heavy, you should use a manual vacuum aspirator to remove the uterus.
• If there is a delay in evacuation, administer ergometrine 0.2 mg IM (again after 15 minutes if necessary) OR misoprostol 400 mcg orally (again once after four hours if necessary).
• In pregnancy greater than 16 weeks give oxytocin 40 units in 1 L IV fluids (normal saline or Ringer's lactate) at 40 drops per minute until expulsion of products of conception occurs, Give misoprostol 200 mcg vaginally every four hours until expulsion, but do not administer more than 800 mcg; if needed.
• Anti D in case of Rh negative mother.
• Give health education on family planning and follow up.

Missed Abortion

In a missed abortion, the fetus has already died, but the placenta and fetal tissue are still present in the uterus. There is a chance that if the dead tissue is kept in the uterus for more than 6 to 8 weeks, the mother might have coagulation problems that could cause significant bleeding.

Sometimes, after a missed abortion, the placenta and fetus develop a blood mole in which they are encircled by clots of blood in the capsular decidua. Usually, it happens during the first trimester. A carneous mole is the meaty, hard mass that is left after a blood mole is held in the uterus for a few months; the fluid has been absorbed.

Sign and Symptoms

• Abdominal pain and vaginal bleeding will stop.
• The signs of pregnancy will disappear Brown vaginal discharge and spotting.
• On histological examination, the fetus may still be found in the centre of this mass.
• Uterine size smaller than the period of amenorrhea.
• Cervix soft and internal os closed.

Management

• Dilatation and suction evacuation are necessary if the uterus is less than 12 weeks old.
• If the uterus is older than 12 weeks, prostaglandin gel should be used to rip the cervix, followed by two hourly injections of prostidin.
• Tetanus toxoid and anti-D in a mother who is Rh negative.
• If necessary, antibiotics and hemostatics.

Induced Abortion

Pregnancy termination happens as a result of interference, which may be caused by a medical or surgical procedure, the use of herbal remedies, or other folk practices that cause the uterus to partially or completely empty of its contents. Depending on the country's legal system, induced abortion may be permitted or prohibited. In 2002, Nepal's abortion laws were loosened. The law went into effect in 2004.

Medical Method

Over the past ten years, mifepristone has been promoted as a non-surgical alternative to abortion. Progesterone antagonist oral mifepristone and oral misoprostol can be used to induce an abortion medically (prostaglandin E1). Only the first 63 days of amenorrhea are allowed for its use.

Within three days, 85% of patients will have an abortion. The success rate increases with earlier gestational age. Only 2% of patients have incomplete abortions and need vacuum curettage.

Surgical Method

• Manual vacuum aspiration
• Suction evacuation
• Dilatation and curettage

Induced abortion may be:

1. Legal abortion:

A medical professional who has been authorized by the country's legal system performs a legal abortion, ending a pregnancy for legal reasons. Additionally, it might be necessary for such a procedure to be performed in a specific way and at a specific location or facility. It is important for midwives to understand the country's abortion laws. No matter the circumstance or the reason, abortion is prohibited in some nations.

2. Illegal abortion

llegal abortion means any abortion which is performed by any person who is not permitted under the relevant law of the country to carry out such a procedure. There is a very high risk of sepsis and/or haemorrhage as well as other injuries.

3. Septic abortion

Septic abortion can happen after any type of abortion, however it happens more frequently after illegal and incomplete abortions. If the infection is not promptly treated, it will quickly spread from the uterus to the fallopian tubes, pelvic organs, and peritoneum and result in septicaemia.

Sign and symptoms

• Sick looking, febrile or jaundiced
• Fever and cramp abdominal pain
• Rapid pulse
• Headache
• Uterus feels tender to palpation

Complication

• Immediate complication
  • Haemorrhage
  • Endometritis
  • Peritonitis
  • Septicemia
• Late complication
  • Pelvic adhesions
  • Infertility
  • PID

Management

• If the lady is in shock, resuscitation measures should include blood transfusion and IV fluids such as RL, NS, and plasma expanders.
• lady admitted for ongoing care in an intensive care unit
• Cervical, vaginal, and urine cultures are acquired, along with blood grouping and cross-matching, complete blood count, serum electrolytes, serum creatinine, blood type and cross-match. Give out 4–6 liters of oxygen per minute.
• Antibiotics: Clindamycin (gram-negative anaerobic coverage), gentamicin (gram-negative aerobic coverage), and penicillin (gram-positive coverage) are frequently combined.
• Hematinics must be administered.
• Set up a foley's catheter to continuously monitor urine production while evaluating kidney function.
• To replenish fluid volume and offer a pathway for high-dose, wide spectrum antibiotic treatment, the intravenous site is opened.
• As needed, analgesics and sedatives.
• For tetanus prophylaxis, either tetanus immune globulin or tetanus toxoid will be administered intramuscularly.
• To remove the remaining diseased or necrotic tissue from the uterus, dilation and curettage will be performed.

Recurrent Abortion/ Habitual Abortion

When a woman has had three or more consecutive pregnancies ending in spontaneous abortion. This may be associated with an, or with general or pelvic disease. Previous trauma to the cervix may be the cause.

Risk Factors

• Often the cause is unknown.
•  Advanced maternal age-where the woman is 235 years of age and the man 240 years of age
• Previous history of miscarriage
• Maternal cigarette smoking and caffeine consumption and heavy alcohol consumption
• Incompetent cervix
• Pelvic abscess
• Chromosomal abnormalities of the embryo account for 30-57% of further miscarriages
• Maternal syphilis, DM, chronic nephritis, essential HTN and Rh incompatibility Hormonal problems Progesterone deficiency, thyroid dysfunction, polycystic ovary syndrome (PCOS). Women with diabetes who have high haemoglobin A1c levels in the first trimester are at risk of miscarriage and fetal malformation.
• Previous trauma to cervix Pelvic disease
• Congenital uterine malformations-bicornuate uterus, septate uterus

Investigation

• Blood grouping Rh- type, Hb, complete blood count
• TORCH titre
• Renal, liver and thyroid function test
• Cervical swab culture
• Urine culture

Management

• Two weeks of rest.
• Women who experience repeated miscarriages should be sent to a specialty clinic.
• Heparin and low-dose aspirin therapy to stop additional miscarriages. Women who have second-trimester loss linked to hereditary thrombophilias may benefit from heparin medication throughout pregnancy in terms of their likelihood of having live births.
• A prediction for future births with an unbalanced chromosomal complement and the chance for familial chromosome studies are provided to the couple through genetic counseling.
• Women who have previously experienced second-trimester miscarriages and who may have cervical weakness should consider getting a cerclage for an ineffective os.
• Encourage the lady to relax and steer clear of strenuous activity, sexual contact, and travel during this time.
• AIDS-related illnesses should be treated.
• Correction of uterine abnormalities through surgery.

Post Abortion Care (PAC)

Post-abortion care is the care given to a woman who has had an unsafe, spontaneous or legally induced abortion. It consists of the following components:

• Treatment of consequences from a spontaneous or risky induced abortion in an emergency situation.
• Services and counseling for family planning.
• Community education to improve reproductive health and lessen the need for abortion. Access to complete reproductive health care, including HIV/AIDS and STIRTIS screening and treatment.

Management of Post-abortion Care [According to World Health Organization (WHO)

It is crucial to keep in mind that these patients deserve empathy, understanding, compassion, and counseling throughout their treatment when delivering post-abortion care services. Prior to providing post-abortion treatment, it's critical to handle the current emergency. Deal with the bleeding and the shock, L.E. Following the stabilization of this woman's condition, it is equally important to offer the necessary follow-up care, such as pain management, emotional support, post-abortion counseling, and any additional tests that might be necessary.

Management of Shock

The main aim when managing shock is to stabilize the patient, as follows:

Universal measures:

• Make sure that the airway is open
• Check vital signs
• NPO the patient as the vomitus may aspirate or inhale by her
• Make woman warm instead of over heat to the woman
• Elevate the legs by placing pillows under feet, elevating foot of the bed or placing the patient in a trendelenburg position to maintain the circulation of the vital organs.
• Give oxygen 6-8 litres per minute by mask or nasal cannulae.
• Give intravenous fluids immediately by large gauge 16-18 and send blood samples for haemoglobin and haematocrit and crossmatch;
• Give sodium lactate or normal saline at a rate of 1 litre in 15-20 minutes (normally it takes approximately 1-3 litres, infused at this rate to stabilize a patient in shock).
• Blood transfusion is required if haemoglobin is 5 g/100 ml or less or haematocrit is 15% or less.

Medication:

• Broad spectrum antibiotics should be started either intravenously or intramuscularly:
•  Tetanus toxoid given subcutaneously or tetanus immune globulin given intramuscularly will be prescribed for prophylaxis against tetanus.
• Manage haemorrhage as the cause of shock in incomplete abortion.

Management of Haemorrhage

If the retained result of conception is still inside the uterus, remove the body to halt bleeding and manage shock as previously described.

The uterine size assessed in completed weeks from LMP will determine the best approach for removing the uterus. The following are the uterine evacuation procedures used in emergency abortion care during the first trimester (up to 12 weeks LMP, or 12 weeks following the start of the last regular menstrual cycle):

Manual Vacuum Aspiration or MVA or Dilatation and Curettage

Examination of the Products of Conception:

The tissue removed from the uterus must be examined immediately following the evacuation procedure, before the woman leaves the treatment/ procedure room. Wear Gloves to prevent from infection.

The tissue should be examined for its completeness.

• Excess blood and small clots should be removed by placing the tissue in a fine strainer and gently pouring water over it. The tissue should then be placed in a clear container of water or saline.
• Add a weak acetic acid solution (vinegar) to the water, any remaining blood will be removed and the villi will be bleached, making them easier to recognize. To inspect the tissue, hold the container in front of a window or light. A magnifying glass or microscope (if available) may be helpful although not absolutely necessary.

Normal Findings on Tissue Examination:

• Villi (white branching projections of placental tissue).
• Gestational sac (transparent membrane attached to the villi).
• Decidua (maternal endometrial tissue that is firm, with coarse shaggy borders).
• Fetal fragments may occasionally be seen at gestations greater than 10 weeks.

Abnormal findings on tissue examination:

• The presence of decidua without villi may indicate incomplete evacuation of the uterus, ectopic pregnancy, completed abortion prior to procedure, or blighted ovum.
• Old blood clots, pus, or foul-smelling material indicate infection/sepsis.
• Grape-like clusters indicate the possibility of a molar pregnancy or hydatidiform mole.
• Repair of cervical or genital tract lacerations by suturing which is the source of laceration.
• If at any time, uterine perforation is suspected as the source of severe bleeding, aspiration must be stopped immediately and appropriate steps taken, such as commencing IV fluids and observation of bleeding and the woman's general condition (vital signs; degree of pallor, pulse, BP, consciousness and urine output) until a careful investigation by laparoscopy or laparotomy has been performed.
• Without delay refer the woman to the higher centre where skilled staff or the required supplies and equipment are available (e.g. for the repair of genital tract lacerations and uterine perforation)

Management of Intra-Abdominal Injury

• Management of shock as mentioned above.
• Surgical procedures. A laparotomy may be required to assess and repair the damage.
• Referral and transfer without delay, sent to the facility where staff with the necessary surgical skills or the required supplies and equipment are available, where appropriate treatment is available.

Management of Sepsis

• Management of shock as mentioned above. Products of conception and other possible sources of infection may be intra-abdominal injury, pelvic abscess, peritonitis, gas gangrene, or tetanus. All sources of infection must be treated. In addition, if the woman has an IUD in place, it must be removed.
• Combination of antibiotics should be given to provide the broadest coverage possible. Useful regimens include:
  • If severe infection involving deep tissue, give: ampicillin 2 g IV stat every 6 hours, and gentamycin 5 mg/kg body weight IV every 24 hours, and metronidazole 500 IV every 8 hours. If infection does not involve deep tissue, give amoxicillin 500 mg orally 3 times a day for 5 days, and metronidazole 400 mg orally 3 times a day for 5 days. Gentamycin Smg/kg body weight IV every 24hours for 5 days.
  • If the woman does not improve within 48 hours of starting antibiotics, or the laboratory report indicates that the bacteria are resistant to the antibiotics given, they must be changed.

Tetanus Immunoprophylaxis.

• Women who took tetanus medication during the last 10 years and have a clean, small wound don't require immunoprophylaxis. A tetanus vaccination booster should be administered if the wound is burnt, punctured, or contaminated with dirt or feces.
• Tetanus vaccine and tetanus antitoxin should be administered to any woman who has not received a full dose of the tetanus vaccine within the past 10 years or who is unsure of her vaccination status.
• Use separate needles, syringes, and sites of administration when administering a vaccination and an antitoxin simultaneously.
• The uterus should be evacuated, preferably using MVA, if the infection is being caused by retained fetal products.
• Eexamination of the aforementioned fetal products.
• Send the woman right away to the higher level facility with the available skilled personnel, supplies, and equipment.

Information, Counselling and Communication

Give information regarding the treatment, condition of the women and keep the information confidential provided during the medical history.

Post-operative information: Inform woman about the normal progress of recovery before discharge and recommend to return to daily activity. Tell her about the possible sign of complications and the place to seek help should these become apparent, and the early return to fertility.

Provide post-abortion family planning counselling and advice, counselling for screening for STIS, RTIS and HIV, unless HIV if not known. The issue of STIs and HIV screening needs to be handled sensitively, especially if the circumstances around the pregnancy were related to forced or unwanted sexual intercourse. For further guidance on voluntary counselling and testing for HIV (VCT), follow national protocol and guidelines.

Family planning counseling

• After an abortion procedure, woman will regain ovulation as early as two to four weeks. Approximately 75% of women who have had an abortion will ovulate within six weeks of the abortion.
• After a first trimester abortion, ovulation often occurs within two weeks, and after a second trimester abortion, within four weeks. Therefore, there is an immediate need for contraception for women who do not want to become pregnant, or for health reasons should delay becoming pregnant.
• As with any family planning client, appropriate screening for contraindications and the provision of information and counselling to ensure informed choice are essential

Communication

• All health workers who have contact with abortion patients should treat them professionally, respectfully and with understanding of the difficulties associated with an unwanted pregnancy and abortion complications.
• Respect the women and make her feel welcome so that woman feels comfortable.

Comprehensive Abortion Care (CAC)

A variety of medical and allied health treatments that help women in exercising their sexual and reproductive rights and health are included in comprehensive abortion care. Three essential components make up a woman-centered model of abortion care: choice, access, and quality.

Choice

"Choice" refers, in its broadest sense, to the ability and privilege to choose among possibilities. Women should be free to make their own decisions regarding their bodies and health without interference from others. However, the ability to make decisions is influenced by a number of variables, such as the policy environment, a functional health system, social and cultural attitudes and practices, and financial resources. Choice in relation to pregnancy and abortion refers to a woman's freedom to choose whether and when to get pregnant, whether to carry a pregnancy to term or not, and which abortion methods, contraception, providers, and facilities to use. A woman's decisions must be supported by complete and accurate information, as well as the ability to consult knowledgeable healthcare professionals with any questions or concerns.

Many women who require abortion treatment are in precarious circumstances that limit their ability to exercise autonomy. They could be forced to undergo an abortion or keep the pregnancy going by relatives or other people. In some situations, medical professionals might only agree to provide care in return for hefty fees or might require the woman to use a specific form of contraception. sterilization is included. The concept of choice is compromised by such limited or restricted options. These kinds of coercive, exploitative practices put women at risk and violate their human rights. Risk to one's health and wellbeing.

Access

To offer abortion treatment for legal reasons, qualified practitioners have a medical and ethical duty. The degree to which a woman has access is influenced, in part, by the accessibility of skilled, technically proficient healthcare professionals who use the appropriate clinical technologies, are conveniently located—ideally in nearby communities and at as many service delivery points as possible. If it takes too long or is too far to get to a designated health facility, a woman's access is hampered. Health systems can direct their resources toward training private clinicians who might serve some communities more readily than public healthcare workers in order to combat this. A woman has better access when services are affordable and delivered in a timely manner without undue logistical and administrative obstacles. Emergency services should always be available regardless of the woman's ability to pay

Access can also be restricted by providers that act disrespectfully, violently, or coercively. Furthermore, a woman shouldn't be denied services because of her marital status, age, economic condition, political beliefs, sexual orientation, racial or ethnic background, education, or social background.

In many societies, access is also influenced by cultural factors. For example, women often have less access to social, health, and educational services than men, which can result in health disparities. For instance, a woman with little control over family finances might have trouble arranging transportation to a medical facility and finding the money to pay for her visit.

Preferences for male offspring, the overbearing influence of in-laws, and the major role of procreation in society are more subtly influencing variables that might restrict women's access to services. The interactions between women and healthcare professionals are also influenced by gender norms and expectations. When receiving treatments for reproductive health from a male clinician, some women could feel ashamed. Some people could be reluctant to make decisions in front of medical professionals or to ask or respond to queries. These kinds of circumstances can have negative health effects and play a significant role in maternal morbidity and mortality.

Sustainability

Access to high-quality treatment is also reliant on the long-term viability of services. The establishment of abortion services must be done in a way that the healthcare system can support.

Health systems must implement staff training programs that inform them about nearby referral services in order to maintain abortion services at the local level. Equipment and medication supplies must be easily accessible, trustworthy, and sufficient, and services must be efficiently managed, monitored, and evaluated. Links between the community and service providers are crucial in preventing unintended pregnancies and unsafe abortions.

These linkages can mobilize resources to help women receive appropriate and timely care for induced abortion or complications from abortion; and can ensure that health services reflect and meet community expectations and needs all factors that contribute to sustainability.

Quality

High-quality abortion care includes many factors that will vary somewhat within local contexts and available resources. Some fundamental components of high-quality care are:

• Tailoring each woman's care to her social circumstances and individual needs.
• Providing accurate, appropriate information and counseling that supports women in making fully informed choices.
• Utilizing internationally recommended medical technologies- particularly manual vacuum aspiration (MVA) and medical abortion-as well as appropriate clinical standards and protocols for infection prevention, pain management, complications and other clinical components of care.
• Offering postabortion contraceptive services, including emergency.

Abortion Law of Nepal

Asia's highest maternal mortality rate is found in Nepal. Unsafe abortion is a major contributor. The Nepal Criminal Code (Muluki Ain) was proclaimed by His Majesty's Government on March 16, 2002, and it received royal assent on Ashoj 10, 2059. (27 September)

Nepal's 2002 Abortion Law

Pregnancy termination is available under these circumstances:

• Up to 12 weeks gestation for any indication, by request.
• Up to 18 weeks gestation in the case of rape or incest. At any time during pregnancy if mental/physical health or life of the pregnant woman is at risk (approval from a medical practitioner required).
• At any time during pregnancy if the fetus is deformed and incompatible with life (approval from a medical practitioner required).

Additional considerations:

• Only providers certified in safe abortion care are eligible to provide induced abortion services;
• The pregnant woman alone has the right to choose to continue or discontinue pregnancy.
• In the case of minors (< 16 yrs of age) or mental incompetence, a legal guardian must give consent.
• Pregnancy termination on the basis of sex selection is prohibited.

Manual Vacuum Aspiration (MVA)

By suctioning out the uterine fetus, manual vacuum aspiration (MVA) is a surgical abortion procedure that was previously used to treat incomplete abortions. The primary requirements for manual vacuum aspiration are that the woman's uterine sizes be equal or less than 12 weeks removed from her last menstrual period, that her hemoglobin level be greater than 7 gm/dl, and that her vital signs be stable.

Advantages of MVA

• Has locking valve
• Vacuum is equivalent to electric pump
• Efficacy is same as electric vacuum (98-99%)
• . Has semi flexible plastic cannula
• Less complications
• Is portable and reusable
• less expansive
• Can be used in any site (remote health post or urban treatment centers).

Step of PAC (According to SBA book / IMPACT)

Initial Assessment

• Greet the woman respectfully and with kindness.
• Determine the uterine size by pelete examination (differ greatly from that determined by DMP) Assess patient for shock and other life threatening conditions.
• If any complications are dentined, stabilise patient and transfer if necessary eg if in shock treat for shock immediately (the signs of shock are BP below 90/50 mm/the pulses 110/min. respiratory rates 30/minute, pallon sweating ansiousness, confusion or unconsciomeness) Check to assess if there is vagmal bleeding, signs of infection and abdominal injury and stabilise patient and transfer.

Medical Evaluation

• Take a reproductive health history
• Perform limited physical (heart, hings and abdomen) and pelvic examinations.
• Perform indicated laboratory tests. Give the woman information about her condition, and what to expect.
• Discuss her reproductive goals as appropriate If she is considering an RUD.
• She should be fully counseled regarding IUD use.
• The decision to insert the IUD following the MVA procedure will be dependent on the clinical situation.

Getting Ready

• Tell the woman what is going to be done, listen to her and respond attentively to her questions and concerns.
• Provide continual emotional support, comfort, reassurance, as feasible.
• Tell her she may feel discomfort during some of the steps of the procedure and tell her in advance,
• Give paracetamol 500 mg by mouth to the woman 30 minutes before the procedure.
• Ask about allergies to antiseptics and anesthetics. Determine that required sterile or high level disinfected instruments are present.
• MVA syringe, different size cannulae, adapters. Color name and cannulae size (blue 4, 5, 6num, tan 7mm, ivory 8mm, dark brown 9mm, dark green 10mm, 12mm)
• MVA set.
• Surgical and utility gloves.

Others

• Strainer.
• Virex.
• Plastic gown, boot, cap, mask.
• Wash disposable container and sharp disposal container.
• Emergency drugs.
• Family planning commodities (at least minimum standard of condom, pills and depo), norplant and IUCD.
• Check that the patient has recently emptied her bladder.
• Make sure that the appropriate size cannulae and adapters are available.
• Check the MVA syringe and charge it (establish vacuum).
• Check if patient has thoroughly washed and rinsed her perineal area.
• Put on personal protective barriers.
• Wash hand thoroughly with soap and water and dry with clean, dry cloth or air dry.
• Put high level disinfected or sterile surgical gloves on both hands.
• Arrange sterile or high level disinfected instruments on sterile tray or in high level disinfected container.

Technical Problems

Syringe is Full (MVA): Keep a second prepared syringe on hand during the aspiration and switch syringes if one becomes full.

Cannula is Withdrawn Rematurely (MVA): If the opening of the cannula is pulled into the vaginal canal with the valve still open, the vacuum will be lost and barrel with the cannula tip still in the uterus.

Syringe does not hold vacuum (MVA): Try lubricating the plunger and barrel with a drop of silicone. If this does not work, replace the O-ring. If the syringe still does not hold a vacuum, discard it and use another syringe

Procedural Problems - MVA

Less than expected tissue/No Product of conception:

• Consider possible ectopic pregnancy.
• Consider complete abortion or misdiagnosis.

Incomplete Evacuation:

• Use correct size cannula.
• May need to repeat evacuation.

Uterine perforation:

• This is rare. Signs include severe pain, abdominal distention, cervical motion tenderness, shoulder pain and rigid abdomen.

Other Problems

Vaginal Bleeding not Due to Pregnancy.

• Break-through bleeding (hormonal contraceptive use).
• Uterine fibroids.

Ectopic Pregnancy

• Delay in treatment of an ectopic is dangerous.

Risk is higher in women with:

• Previous ectopic pregnancy.
• Pelvic infection.
• IUD or progestin-only contraceptive use.

Procedure Task

• Check for signs of manual vacuum aspiration (MVA) before 16 weeks, which is a necessary abortion. Molar pregnancy, incomplete abortion, or delayed PPH brought on by residual placental pieces
• Give paracetamol and offer emotional support and encouragement 30 minutes before the surgery.
• If required, use a paracervical block.
• Get the MVA syringe ready. Put the syringe together; Snap the pinch valve shut. - until the plunger arms lock, pull back on the plunger.
• Give oxytocin 10 units IM or ergometrine 0.2 mg IM before to the surgery, even if bleeding is minimal, to firm up the myometrium and lower the chance of perforation. Bimanually examine the pelvis to determine the fornices' health and the size and location of the uterus.
• Insert a speculum or vaginal retractor into the vagina. Apply antiseptic solution to the vagina and cervix (especially the os).
• Check the cervix for tears or protruding products of conception. If products of conception are present in the vagina or cervix, remove them using ring or sponge forceps. . Gently grasp the anterior or posterior lip of the cervix with a vulsellum or single-toothed tenaculum.
• If using a tenaculum to grasp the cervix, first inject 1 mL of 0.5% lignocaine solution into the anterior or posterior lip of the cervix which has been exposed by the speculum. Dilatation is needed only in cases of missed abortion or when products of conception have remained in the uterus for several days:
• Gently introduce the widest gauge suction cannula;
• Use graduated dilators only if the cannula will not pass. Begin with the smallest dilator and end with the largest dilator that ensures adequate dilatation (usually 10-12 mm)
• Take care not to tear the cervix or to create a false opening.
• While gently applying traction to the cervix, insert the cannula through the cervix into the uterine cavity just past the internal os. (Rotating the cannula while gently applying pressure often helps the tip of the cannula pass through the cervical canal).
• Slowly push the cannula into the uterine cavity until it touches the fundus, but not more than 10 cm. Measure the depth of the uterus by dots visible on the cannula and then withdraw the cannula slightly
• Attach the prepared MVA syringe to the cannula by holding the vulsellum (or tenaculum) and the end of the cannula in one hand and the syringe in the other
• Release the pinch valve(s) on the syringe to transfer the vacuum through the cannula to the uterine cavity.
• Evacuate remaining uterine contents by gently rotating the syringe from side to side (10 to 12 o'clock) and then moving the cannula gently and slowly back and forth within the uterine cavity.

Note: To avoid losing the vacuum, do not withdraw the cannula opening past the cervical os. If the vacuum is lost or if the syringe is more than half full, empty it and then re-establish the vacuum

Note: Avoid grasping the syringe by the plunger arms while the vacuum is established and the cannula is in the uterus. If the plunger arms become unlocked, the plunger may accidentally slip back into the syringe, pushing material back into the uterus

Check for signs of completion: Red or pink foam but no more tissue is seen in the cannula; A grating sensation is felt as the cannula passes over the surface of the evacuated uterus, The uterus contracts around (grips) the cannula.

Withdraw the cannula: Detach the syringe and place the cannula in decontamination solution. With the valve open, empty the contents of the MVA syringe into a strainer by pushing on the cannula.

Cannula is clogged (MVA): Never try to unclog the cannula by pushing the plunger back.

Note: Avoid grasping the syringe by the plunger arms while the vacuum is established and the cannula is in the uterus. If the plunger arms become unlocked, the plunger may accidentally slip back into the syringe, pushing material back into the uterus.

Note: Place the empty syringe on a high-level disinfected or sterile tray or container

• Remove the speculum or retractors and perform a bimanual examination to check the size and firmness of the uterus.
• Quickly inspect the tissue removed from the uterus: for quantity and presence of products of conception; to assure complete evacuation; to check for a molar pregnancy (rare). If necessary. strain and rinse the tissue to remove excess blood clots, then place in a container of clean water, saline or weak acetic acid (vinegar) to examine. Tissue specimens may also be sent for histopathologic examination, if required.
• If no products of conception are seen: All of the products of conception may have been passed before the MVA was performed (complete abortion);
• The uterine cavity may appear to be empty but may not have been emptied completely. Repeat the evacuation
• The vaginal bleeding may not have been due to an incomplete abortion (e.g. breakthrough bleeding, as may be seen with hormonal contraceptives or uterine fibroids)
• ; The uterus may be abnormal (i.e. cannula may have been inserted in the nonpregnant side of a double uterus).
• Note: Absence of products of conception in a woman with symptoms of pregnancy raises the strong possibility of ectopic pregnancy.
• Gently insert a speculum into the vagina and examine for bleeding. If the uterus is still soft and not smaller or if there is persistent, brisk bleeding, repeat the evacuation.

Post Procedure Patient Care

• Give paracetamol 500 mg by mouth as needed.
•  Allow the patient to rest comfortably for at least 30 minutes where her recovery can be monitored. ⚫ Check for bleeding and ensure that cramping has decreased before discharge.
•  Advice the woman about signs of normal recovery.
• Offer other health services, if possible, including tetanus prophylaxis, counseling or a family planning method. Counsel for different FP methods informed choice and importance of starting post abortion family planning method. Counsel about different FP methods informed choice and importance of starting post abortion FP immediately because ovulation may occur by day 11 post abortion, 75% of women will have ovulated within 6 weeks post abortion.
• Vaginal bleeding or spotting for a few days, but no more bleeding than with a typical menstrual period.
• Uterine cramping that may be relieved with analgesia.
• Tell her when to return if follow up is needed and that she can return anytime she has concerns.
• Encourage the woman to eat, drink and walk about as she wishes. Offer other health services, if possible, including tetanus prophylaxis, counselling or a family planning method. Discharge uncomplicated cases in one to two hours.
• Advise the woman to watch for symptoms and signs requiring immediate attention:
  • Prolonged cramping (more than a few days);
  • Prolonged bleeding (more than two weeks);
  • Bleeding more than normal menstrual bleeding;
  • Severe or increased pain;
  • Fever, chills or malaise;
  • Fainting.

 Post Procedure Care

• Put waste items in a leak-proof container or plastic bag before taking off your gloves. For decontamination, soak all instruments in a 0.5% chlorine solution for ten minutes.
• Put a needle or syringe in the designated disposal.
• Put the used cannula on the MVA syringe, and then use 0.5% chlorine solution to flush both.
• For decontamination, separate the cannula from the syringe and soak it in a 0.5% chlorine solution for 10 minutes. • Pour POC into a toilet that can be flushed, a latrine, a utility sink, or a container with a tight-fitting lid.
• Put your hands in a 0.5% chlorine solution while wearing gloves.
• Turn the gloves inside out to remove them. Put the gloves in a leak-proof container or plastic bag before throwing them away. If you plan to reuse your surgical gloves, decontaminate them for 10 minutes in a 0.5% chlorine solution.
• Using a clean, dry cloth or letting them air dry, thoroughly wash your hands with soap and water.

Complication

• Incomplete evacuation
• Cervical laceration
• Haematometra
• Shock
• Vaginal react
• Uterine perforation
• Pelvic infection
• Haemorrhage
• Air embolism