Threatened Abortion

Threatened abortion- is the type of miscarriage where the process of abortion has started but not worse to the extent that pregnancy can not be maintained if emergence clinical intervention has been done. In this type of abortion recovery can be possible.

       Clinical symptoms
-Before coming up with the diagnosis of threatened abortion, history and confirmatory test should be done to make sure, the patient is a pregnant in-order to rule out other obstetrics and gynecology conditions. Therefore the patient should a pregnant who present with the following symptoms:-
               -slightly bleeding per vagina
               -mild back or lower abdominal pain
              
-Speculum examination and per vagina examination (reveal the closed cervix) should be done to rule out ectopic pregnancy, molar pregnancy, cervical ectopy, fibroid and carcinoma.

-Basic investigations like hemoglobin level, blood group and cross match and hematocrits level should be done soon as possible. Urine test for viability of pregnancy may be unreliable, because it may be positive even several days after fetus death. Ultrasound is very important because it can be used to observe fetal cardiac movement, fetal movement and other  parameters.

 
      Treatments
 -the patient should be in bed/rest for few days until symptoms are no longer present.
 -sexual intercourse should be avoided because it may provoke symptoms and make the  condition     worse.
 -anti-pain drugs should be given to relief pain and diazepam may added.

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Spontaneous abortion ( Miscarriage)

                                               

Abortion is the extraction or expulsion of the embryo or fetus weighing 500g or less from its mother before it can survive alone. This 500g is usually attained by the fetus around 22 weeks of gestation. The products of abortion is called abortus. 

The incidence of abortion may be difficult to find out but according to current study is about 10-20% of all clinical pregnancies end in abortion and another 10% are induced illegally. 75% of all abortion occur before the 16 weeks of gestation .

Abortion has been classified into several subgroups. The main one is spontaneous abortion or miscarriage (occur naturally) and the other one induced abortion (initiated artificially). Spontaneous abortion is of clinical important and is the one will be explained here.

Spontaneous abortion has been subdivided into several groups which are threatened, inevitable, complete, incomplete, missed and septic abortion. Each type will be explained in details separately in the following post.

The etiology/causes of spontaneous abortion is complex and difficult to find out. The following factor are important and with the positive association:-


     Genetics-About 50% of all early spontaneous abortion occur due to chromosomes abnormalities in the conceptus. This include autosomal trisomy is the commonest one for about 50% and the commonest triosomy is 16 (30%).  polyploidy 22% (presences of three or more haploid  number of chromosomes) has been reported and the commonest one is triploidy. Other are monosomy and structural chromosomes rearrangement has been reported to cause miscarriage.

     Endocrine and metabolic factors- deficient in progesterone hormone or poor uterine response to the progesterone is the cause. conditions like hypothyroidism or hyperthyroidism has association with abortion. Poorly or uncontrolled diabetic mellitus has been linked to result in miscarriage.   

 
     Anatomical abnormalities- cervical and uterine factors like cervical incompetence, congenital malformation of the uterus has been associated with pregnancies lose especially during the second trimester. Condition like uterine fibroid and uterine adhesion has positive effect on pregnancy loss because of reduced uterine volume, interfere with implantation, placentation and fetus growth. 

    Infections- infections such as viral infections ( rubella, cytomegalo and even HIV infection), bacterial infections ( chlamydia, syphilis, and others ), parasitic infections ( malaria, and toxoplasma) are hardly result in abortion before 20 weeks of gestation because of effective thickness of placental barrier.


   Immunologic disorders- autoimmune disorder like antinuclear antibodies can cause miscarriage usually in the second trimester. Alloimmune disease may result into fetal rejection by maternal antibodies and hence miscarriage occur.Antifetal antibodies in case Rhesus isoimmunization where  by the mother is rhesus negative and the fetus is rhesus positive can usually cause spontaneous abortion.

   Other factors- maternal medical illness like cyanotic heart disease and hemoglobinopathy has been associated with early pregnancy loss. Premature rupture of membrane, cigarette smoking and alcohol used during pregnancy has increase the incidence of miscarriage.


  Unexplained etiology- around 40-60% of all miscarriage cases has no know etiology despite all of the above explained factors. However the risk of miscarriage increase with maternal age. More than 20% of all pregnancies diagnosed using urine pregnancy test, are lost before the clinical diagnosed. 




                 DR MWANDA.

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Third stage of labor

Third stage of labor.

The third stage of labor begin after delivery of the fetus and end with delivery of the placenta and its membrane. The average time for this stage is about 15 minutes. The separation of placenta from the uterus occur due uterine contraction which results into reduced in uterine surface area of the placental site following delivery due to uterine retraction. This stage is managed according to WHO protocol of third stage of labor management.

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Second stage of labor

Second stage of labor.

The second stage of labor begin from a full dilation of cervix and end with delivery of the fetus. Approximately time of this stage is 2 hours during the first pregnancy and 30 minutes in the following pregnancy. This stage is manifested with increase in frequency of uterine contractions and bearing down effort which result in delivery of the fetus.

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First stage of labor

first stage of labor


First stage of labor begin from the onset of true labor pain and end with the full dilation of the cervix. The approximately time is 12 hours during the first pregnancy and 6 hours in following pregnancy. Dilation of cervix up to 3cm is called a latent phase and dilation of cervix to 10cm is called active phase of first labor.
 This stage is clinically accompanied  with progressive uterine contractions, cervical dilation and rupture of membrane. Maternal and fetus remain normal in this stage except during uterine contractions, where fetus heart rate will be reduced physiologically.
 At this stage, no much intervention done rather than let nature takes its own place. Women should be encouraged, given support, make them stable psychologically and in some areas anti pain  is given in the course of labor. 

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Gonorrhea infection; symptoms,signs,diagnosis, treatment and prevention.

GONORRHEA:

 

Gonorrhea remains still as an important health problem especially in developing countries because of poor level of knowledge on Sexually transmitted infections ( STIs). Gonorrhea is caused by organism known as Neisseria gonorrhoeae. When a person become infected , it takes about 3-7 days for this bacteria organism to multiply and increase in number.

Usually this organism, enter the body through the epithelium layers covering genitalia and urinary system. The primary site of infections are urethra, cervix and glands like bartholin and skene`s gland. The organism may only affect lower genitalia tract and produce infections of cervix (cervicitis) , infection of the urethra (urethritis) and glands. Oral cavity, pharynx, anus, rectum and conjunctiva are the other common sites in the body infected with this organism.

About 15% of untreated cervicitis, gonorrhea infection may spreads by ascend and produces infections of the pelvic known as pelvic inflammatory diseases (PID). Sometimes in few patients, the infections may infect the blood ( septicemia) and results into infections of several joints in the body. The gonorrhea infection can also spreads along the sperms to infect upper genitalia organs like uterus, Fallopian tubes and sometimes ovaries. Infection of uterus and Fallopian tube is common. Neisseria gonorrhoeae is usually manifest with others sexual transmitted infection especially Syphilis and chlamydial infections.

    clinical features.

About half of people with gonorrhea, do not show any symptoms of the disease and are the one responsible in a higher percentage for transmission of this disease to uninfected people. The symptoms depend on the part of genital or urinary tract infected. The commonest symptoms are :

           -painful or difficult urination

           -foul smell vaginal discharge

           -pain on one side of vagina and swelling of the labia due to infection of Bartholin gland.

           -pain during or after sexual intercourse 

signs:

          -labia infected and look inflamed.

          - mixture of mucus and pus vaginal discharge is the common sign

           - cervix examination may reveal infection of the cervix. 

Other organs like liver and joints may also affected by gonorrhea especially when the infection infect blood (septicemia) and spread to distant area of the body. In case of septicemia symptoms like fever, generalized joint pains, pain along the level of stomach (epigastric pain) due to infection of liver and skin rashes may occur.

 complications:

The following are common complications of gonorrhea infection, if left untreated or poorly treated;

       - it may result in a chronic pelvic pain

       - infertility is the common complication

       -difficult or painful sexual intercourse

       -abscess of  genitalia gland especially bartholin gland

       - implantation   of the pregnancy outside of uterine cavity( womb).

  Diagnosis

Gonorrhea can be diagnosed clinically from above symptom and signs, but others sexual transmitted infection like Chlamydia can present almost the same as gonorrhea infection. Therefore, the definitive diagnosis of gonorrhea, can be done using Nucleic acid amplification test of the urine or genitalia discharge. Culture of urine or discharge from the genitalia can be done to isolated Neisseria gonorrhoeae organism and drugs sensivity can also be done. 

Treatment

   The common drugs recommend for the treatment of acute gonorrhea infection are the ceftriaxone 250mg IM  plus azithromycin 1gm  once orally and doxycline 100 mg orally every twelve hours for 7 days.

Prevention

  -definitive therapy should be give and the patient should be followed by health provide until cured.

  - both partners should be treated in the same time in order to avoid reinfection from untreated partner.  

     

                                 thanks.

 by

   DR MWANDA. 

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