Here’s the **clean and complete extracted text** from all six uploaded pages — formatted clearly for study and note-making 👇 --- ## **OBSTETRIC COMPLICATIONS — ABORTIONS : PART 1** ### **Definitions** * **Abortion:** Pregnancy loss occurring at < 20 weeks of gestation. * **WHO Definition:** Any pregnancy loss occurring with fetal weight < 500 g (~22 weeks). * **Intrauterine Death:** Any pregnancy loss occurring at ≥ 20 weeks. > **Note:** Period of viability in India: 28 weeks. --- ### **Types of Abortions** **1. Spontaneous** * **Isolated:** Single episode * **Recurrent:** ≥3 abortions * **Subtypes:** * Threatened * Inevitable * Incomplete * Complete * Missed * Septic abortion (any abortion + septic foci) **2. Induced (Medical Termination of Pregnancy)** --- ### **Isolated Abortion** **Causes:** * **Most common (m/c):** Chromosomal anomaly (first or second trimester) * **Common anomalies:** * Aneuploidy > Trisomy > Monosomy (Turner’s) > Trisomy 16 **Risk Factors:** 1. Previous history of abortion 2. Increased maternal age 3. Infections – *Do not cause recurrent abortion* * **Congenital syphilis:** * *Kassowitz’s Law*: Prognosis ∝ number of pregnancies in syphilis patient * *Stillbirth* more characteristic **Notes:** * Most lethal: **Trisomy 16** * Most viable: **Trisomy 21** * **HIV** is *neither abortogenic nor teratogenic*. --- ### **Recurrent Abortion** **Definition:** ≥3 consecutive pregnancy losses at < 20 weeks gestation. **ASRM Definition:** ≥2 confirmed pregnancy losses (by HPE or USG). **Common causes:** * **Endocrine > Uterine** * **Most common cause:** APLA Syndrome **Endocrine causes:** 1. Hypothyroidism (most common) 2. Uncontrolled diabetes 3. PCOS 4. ↑ Prolactin **Uterine causes:** * **Congenital:** Septate > Bicornuate uterus * **Acquired:** * Cervical incompetence (only 2nd trimester abortions) * Submucous fibroid * Ashermann syndrome **Chromosomal abnormalities:** * Cause 2–5% of recurrent abortions. * m/c: Balanced translocation (detected by parental karyotyping). **Investigations:** * **To be done after 2 abortions:** 1. TSH (if endocrine suspected) 2. TVS (if uterine suspected) 3. APLA antibody testing 4. Parental karyotyping **Not done:** 1. TORCH 2. VDRL 3. Thrombophilia --- ### **Cervical Incompetence** **Definition:** Spontaneous dilatation of incompetent internal os → painless 2nd trimester abortion. **Diagnosis:** * **History:** ≥3 painless 2nd trimester abortions. * **In non-pregnant females:** * Passage of Hegar dilator No. 8 without resistance (pre-menstrual phase). * Passage of Foley’s catheter (No. 16, bulb with 1 mL water). **Transvaginal Scan (TVS):** * Investigation of choice in pregnancy. | Parameter | Normal | Cervical Incompetence | | ---------------- | ------------------------ | --------------------- | | Length of cervix | 4–5 cm in pregnant women | ≤2.5 cm | | Shape of cervix | T | Y → V → U | > **Note:** Length of cervix ∝ 1 / Dilatation (due to taking up of cervix) --- ### **Management** #### **Cervical Cerclage** **Principle:** Sutures around internal os. **Indications:** 1. H/O ≥2 painless abortions — history-based 2. H/O 1 painless abortion + cervical length < 2.5 cm — USG-based 3. H/O early preterm labour + cervical length < 2.5 cm 4. Pregnant female <24 weeks + dilated cervix — emergency cerclage **Earliest cerclage:** At 12 weeks. --- ### **Progesterone Therapy** * **Purpose:** Prevent preterm labour. * **Start:** 12–24 weeks. * **Stop:** 36 weeks. **Indications:** * Any painless abortion or preterm labour history. * Cervical length < 4.5 cm. * If cerclage done. --- ### **Cervical Cerclage Overview** * **Principle:** Suture around internal os. * **Earliest done at:** 12 weeks. * **Mode of delivery:** Vaginal. --- ### **Management Protocol** **If pregnant woman presents with h/o abortion:** * ≥2 painless abortions → Progesterone at ≥12 weeks + Cerclage. * 1 painless abortion → USG at 14 weeks: * Cervix < 2.5 cm → Cerclage + Progesterone * Cervix ≥ 2.5 cm → Progesterone only **If cervix 4 cm dilated (membranes intact):** → **Rescue/Emergency cerclage**, if no infection. --- ### **Types of Cerclage** 1. **Transabdominal:** * Done if transvaginal fails. * Suture left in place → delivery via LSCS. * ↑ Technical difficulty. * Sutures removed after family completion. 2. **Transvaginal (most common):** * Sutures removed at 37 weeks. * Vaginal delivery possible. * Less accurate suture placement. --- ### **Types of Vaginal Cerclage** | Parameter | McDonald Cerclage | Shirodkar Cerclage | | --------------------- | -------------------------------- | -------------------------------- | | Type of suture | Purse-string in portio vaginalis | Continuous | | Dissection of bladder | Not done | Done (suture closes internal os) | | Success rate | Lower | Higher | | Material | Non-absorbable (polypropylene) | Mersilene tape | **Illustrations:** * McDonald: Purse-string suture around cervix. * Shirodkar: Deeper, closer to internal os. --- ### **Wurm’s Cerclage (Emergency)** **When:** Cervix is already dilated. **Procedure:** * Sutures applied in AP and transverse directions. * **Timing:** Between 14–24 weeks (RCOG: up to 28 weeks). * **Suture removal:** At 37 weeks (earlier → preterm labour / rupture of membranes). --- ### **Abdominal Cerclage** **Indication:** If vaginal cerclage fails. **Technique:** * **Laparoscopic:** For pregnant or non-pregnant. * **LASH/LASH surgery (outdated):** Part of cervix removed before suture. * Performed in non-pregnant; conception avoided for 3 months post-surgery. --- ### **Drugs Used in Cerclage** #### **Tocolytics** * **Indication:** USG-based (cervix length < 25 mm) & emergency cerclage only. #### **Antibiotics** * **Indication:** Emergency cerclage with bulging membranes. * *Not routinely recommended otherwise.* --- ### **Contraindications of Cerclage** **Absolute:** 1. Uterine contractions (preterm labour). 2. Fetal distress. 3. Fetal anomaly. 4. Ruptured membranes. 5. Vaginal bleeding (P/V). 6. Current pelvic infection. **Relative:** * Placenta previa. --- ✅ **Source:** *Marrow Obstetrics v1.0 • 2024 Edition* --- Would you like me to now **generate 15 hard case-based MCQs (with explanations and answer keys)** from this extracted content on **Cervical Incompetence and Cerclage** in a single HTML, CSS, JS file format (for your study app)? Here’s the **complete, accurate extracted text** from the 3 new uploaded pages — formatted for clarity, study, and notes 👇 --- ## **OBSTETRIC COMPLICATIONS — ABORTIONS : PART 2** --- ### **APLA Syndrome (Antiphospholipid Antibody Syndrome)** **Definition:** Acquired autoimmune disorder characterized by antibodies against phospholipids → **thrombosis**. **Pathology:** Antibodies against phospholipids cause hypercoagulability and thrombosis. **Antibodies involved:** * Lupus anticoagulant antibody * Anti-cardiolipin antibody * Anti-β₂ glycoprotein antibody **Presentations:** * **Arterial thrombosis:** Cerebral infarct, myocardial infarction * **Venous thrombosis** * **Placental thrombosis → Leads to:** * Abortions (1st or 2nd trimester) * Uteroplacental insufficiency (IUGR, PIH) * Preterm labour (PTL) --- ### **Diagnostic Criteria** **Modified Sapporo (Sydney) Criteria:** → *At least one clinical + one lab criterion required.* **Clinical Criteria:** 1. History of arterial or venous thrombosis 2. ≥3 first-trimester abortions (<10 weeks) 3. ≥1 fetal loss >10 weeks 4. ≥1 preterm labour (<34 weeks) due to UPI or PIH **Laboratory Criteria:** 1. Anti-cardiolipin antibody (IgM/IgG) detected on 2 occasions, ≥12 weeks apart 2. Anti-β₂ glycoprotein antibody (IgM/IgG) detected on 2 occasions, ≥12 weeks apart > **Note:** Lupus anticoagulant antibody cannot be directly detected by ELISA > > * *In vitro:* anticoagulant property > * *In vivo:* thrombotic effect **Indirect detection:** * Prolonged Russell’s viper venom clotting time * Prolonged kaolin clotting time * Isolated ↑ aPTT --- ### **Management of APLA Syndrome** * If **history of thrombosis or abortion** → **Heparin + Aspirin** * If **history of preterm labour (due to UPI)** → **Aspirin only** * Start when pregnancy confirmed (UPT +ve) * Heparin started once intrauterine pregnancy confirmed * **Stop anticoagulants intrapartum:** * 6 hours after vaginal delivery * 12 hours after LSCS * **Continue postpartum** (as above) * **Non-pregnant females with history of thrombosis:** **Warfarin (DOC)** --- ## **Types of Abortion** | **Type** | **C/O** | **Height of Uterus (P/A)** | **Internal OS** | **USG Findings** | **Management** | | ----------------------- | ---------------------------------------------------- | -------------------------- | -------------------------- | ------------------------ | ------------------------------------------------------------------------------------ | | **Threatened Abortion** | Spotting P/V, pain ± | Equal to POG | Closed | Cardiac activity present | Reassurance, avoid intercourse, progesterone (benefit ill-defined), hCG (no benefit) | | **Inevitable Abortion** | Bleeding P/V, abdominal pain | Equal to POG | Open | Cardiac activity absent | Expedite abortion – medical or suction evacuation | | **Incomplete Abortion** | Bleeding + pain abdomen, h/o expulsion of some POC | < POG | Open (POC seen coming out) | Incomplete POC | Maintain vitals, manage shock, expedite abortion | | **Complete Abortion** | H/O bleeding + expulsion of POC, no current bleeding | < POG | Closed | Empty uterus | Reassurance, Anti-D if Rh –ve | > **POC:** Products of conception > **POG:** Period of gestation --- ## **Missed Abortion** **Definition:** USG-based diagnosis. **C/O:** No symptoms; may have brown discharge. **Height of uterus (P/A):** < POG **Internal OS:** Closed **USG Findings:** * Mean sac diameter ≥ 25 mm with no fetal pole * Crown-rump length ≥ 7 mm with absent cardiac activity * Previously present cardiac activity now absent **Management:** * **Medical abortion** * **Suction evacuation** --- ## **Abortion with Features of Shock** **Most common causes:** * Septic abortion > Incomplete abortion **Special associations:** * H/O abortion + ↑ aPTT → **APLA Syndrome** --- ## **Septic Abortion** **Definition:** Presence of septic foci in any abortion. **Symptoms:** * Fever, chills * Abdominal pain * Diarrhoea, vomiting * Purulent vaginal discharge * May present with **toxic shock syndrome** --- ### **Grading of Septic Abortion** | **Grade** | **Description** | | --------- | ------------------------------------ | | **I** | Infection limited to uterus | | **II** | Infection spread to pelvic organs | | **III** | Peritonitis, shock, or renal failure | > **Note:** Toxic shock syndrome (TSS) is **never caused by E. coli.** --- ### **Management** **Antibiotic therapy:** * **Ampicillin + Gentamicin + Metronidazole** --- ✅ **Source:** *Obstetrics v1.0 • Marrow 8.0 • 2024 Edition* --- Would you like me to now create a **stylish HTML + CSS + JS file** that: * Displays this full extracted content neatly, * Includes **search + section toggle**, * And adds **15 high-yield case-based MCQs** from *APLA Syndrome, Types of Abortion, and Septic Abortion*?