Abortion (Miscarriage)

Abortion /miscarriage is defined as the loss of a pregnancy before 28 weeks gestation.
Types Of Miscarriage
1. Spontaneous abortion
2. Induced abortion

Induced Abortion : This a deliberate termination of pregnancy for various reasons.
Induced abortion can either be:

• Safe
• Unsafe or criminal abortion. 

Spontaneous Abortion : This is when abortion /miscarriage occurs without being deliberately initiated.
Types Of Spontaneous Abortion

• Threatened abortion 
• Inevitable abortion 
• Incomplete abortion 
• Missed abortion 
• Habitual abortion.

Threatened abortion : this is characterized by slight vaginal bleeding in early pregnancy. It may or may not be associated with lower abdominal pain. Fetus is usually still viable.

Inevitable abortion : this is characterized by vaginal bleeding and lower abdominal pain. At this stage nothing could be done to salvage the pregnancy. Vaginal bleeding is usually moderate to severe.

Incomplete abortion : here some products of conception have been passed out and other remaining products are retained within the uterus. Vaginal bleeding is usually severe with associated severe abdominal pain.

Complete abortion : in this type, there is complete passage of all the products of conception. Vaginal bleeding and abdominal pain subside indicating completion of the miscarriage. However, a pelvic ultrasound scan should be done in other to confirm that the uterus is empty.

Habitual abortion : thia is said to occur when 3 or more consecutive spontaneous miscarriage occur in a woman.

Septic abortion : this is said to occur if the products of conception is infected while still in the uterus. Symptoms of septic abortion include, fever, abdominal pain, foul smelling vaginal discharge, chills, headache, etc.


Termination Of Pregnancy (TOP)
This consists of procedures which are applied in deliberately halting the pregnancy process.

Therapeutic Abortion :
This refers to planned termination of pregnancy before the gestational age of viability (which is 28 weeks in our environment) for specific health indications.
Some Reasons For Therapeutic Abortion Include :

• Maternal diseases such as severe heart diseases,  severe pulmonary tuberculosis, chronic kidney diseases, malignant diseases (cancers), severe live diseases. 
• Fetal conditions such as severe viral infections, certain hereditary or severe genetic abnormalities. 

Legal Abortion :
Abortion is legal in many developed countries of Europe and some states in the USA. In these countries, abortions are conducted in a safe manner in accredited hospitals with little or no complication.

Illegal Abortion :
Abortion is however illegal and criminal in most developing countries including Nigeria. Both the woman and the person conducting the illegal abortion are liable to various terms of imprisonment. Illegal /criminal abortion is associated with high rate of maternal morbidity and mortality.


Ectopic Pregnancy
This is the implantation of an embryo at sites other than uterine cavity. Ruptured ectopic pregnancy is a common indication of emergency admissions in gynecological wards. This is usually associated with sudden onset of abdominal pain and intra abdominal bleeding. The commonest site of ectopic implantation is Fallopian tubes and this is seen 98% of cases of ectopic pregnancy.

Heterotopic pregnancy
This is rare situation where by an intrauterine pregnancy may co-exist with an ectopic pregnancy.
Sites Where Ectopic Pregnancy Can Occur :

• Fallopian tubes 
• Cervix
• Ovary
• Broad ligament 
• Peritoneum. 

Causes Of Ectopic Pregnancy

• Infection of the Fallopian tubes 
• Adhesions which occurred after surgery 
• Hormonal contraceptives especially progesterone based ones
• Ovulation induction 
• Previous abortion 
• Previous ectopic pregnancy 
• History of infertility. 

Symptoms And Signs Of Ectopic Pregnancy

• Sudden onset of lower abdominal pain 
• Amenorrhea (missed period) 
• Vaginal bleeding (which may not occur in all cases) 
• Fainting which is usually due to severe loss of large volume of blood from ruptured ectopic pregnancy site.

Treatment
The treatment if ectopic pregnancy depends on whether it is either ruptured or not. Where ectopic pregnancy is ruptured, surgical  treatment is required while is certain unruptured cases, drug treatment is permissive.


Infertility
Infertility is defined as the inability of the woman to achieve pregnancy despite regular, timed, unprotected vaginal sexual intercourse lasting over a period of 12 months.
Types Of Infertility

• Primary infertility : this is a situation where the woman has never conceived in her life time. 
• Secondary infertility : is a situation where  woman who has achieved pregnancy in the past regardless of the outcome is unable to conceive despite regular sexual intercourse. 

Causes Of Infertility
Infertility is caused by male factors (30%)or female factors (30%). However, in some cases, the combination of both male and female factors (30%) are implicated. In 10% of the cases, there is no demonstrable cause.
Male Factors

• Inadequate sexual exposure (protracted abstinence) 
• Damage of cash deferent
• Testicular disorder eg. Mumps infection, STIs, abnormal formation 
• Drug abuse such excessive alcohol intake and cigarettes smoking, marijuana. These reduces sperm count
• Use of tight fitting underpants may be an association
• Varicocoeles which leads to poor sperm production. 

Female Factors
1.Cervical factors : sperm cells pass through the cervix in order to get the Fallopian tube where fertilization takes place. The cervix produces slimy fluid called the cervical mucus. This occurs more during ovulation. It allows for the smooth passage of the sperm cells through the cervix. The absence of cervical mucus or its thickness prevents smooth movement of sperm cells through the cervix hence may contribute to infertility.

2.Tubal factors : several factors which cause damage or blockage of the Fallopian tubes can lead to infertility. These include :

• Pelvic infections : pelvic inflammatory disease which usually follows infection by Chlamydia, Gonorrhea, and in some cases, tuberculosis. 
• Puerperal and post abortal sepsis / infection 
• Peritubal adhesions following pelvic surgeries. 

3. Ovulation factors : the failure of ovulation leads to infertility. Ovulation involves a combination of complex hormonal events which leads to the release of ova by the ovaries.

4. Uterine factors : these may include uterine fibroids, uterine adhesion, etc.

Management Of Infertility
Here a comprehensive examination q ND treatment is required.
Treatment modalities employed in male factors may include :
1. Vaso-vasostomy : this is a surgical procedure which involves removal of the blocked portion of the bad deferens which is the tube that carries sperm cells from the testes to the urethra.

2. Varicocoelectomy : this is a surgical lesions involving the removal of varicose testicular veins.

3. Medical treatment of the various genital tract infections

4. Artificial insemination : this involves artificially introducing semen directly into the vaginal, cervix or uterus. This procedure makes use of either the husband's semen or donor semen.

5. Treatment modalities applied in the management of female factors include the following :

• Estrogen supplement especially where there is poor production of cervix mucus.
• Ovulation induction especially in cases of an ovulatory (no ovulation) cycles. 
• Myomectomy for symptomatic fibroids as well as situations where fibroid masses could be a risk for infertility. 
• In vitro fertilization and embryo transfer.