Comprehensive

Abortion care

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 Objective
At the end of the section the student will able to :-

 Define the term abortion

Identify different types of abortion

Determine components of comprehensive abortion

care

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Abortion
Definition

• Abortion is the spontaneous or induced termination of

pregnancy before fetal viability

• (before 20weeks or <500grams according to WHO or

• before 28 weeks of gestation or less than 1kg fetal

weight in Ethiopia and UK).

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Classification
1. Based on Clinical presentation/clinical stage
a) Threatened Abortion
b) Inevitable Abortion
c) Incomplete Abortion
d) Complete Abortion
e) Missed Abortion

2. Based on trimester
a) 1st Abortion
b) 2nd Abortion

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 Classification …
3.Based etiology
a) Spontaneous Abortion
b) Induced Abortion

4. Based on the presence of infection

a) Septic Abortion
b) Aseptic Abortion

5. Based on circumstance of abortion service

a) Safe
b) Unsafe
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 Spontaneous abortion
• Spontaneous abortion, also known as miscarriage, where
termination is not provoked deliberately

Etiologies

1) Fetal factors

• chromosomal abnormalities
῀50% of spontaneous abortions occurring during the first
trimester

• Trauma e.g. amniocentesis

• Congenital anomalies
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 Spontaneous abortion……. Etiology
2) Maternal Factors
Maternal infections

Endocrine disorders

Uterine defects
 Acquired e.g.. Asherman syndrome

 Developmental

 Incompetent cervix

Immunologic Disorders e.g. Blood group incompatibility

Malnutrition
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Spontaneous abortion…….Etiologies
3)Toxic factors
Radiation

antineoplastic drugs

anesthetic gases

Alcohol

 smoking

4)Trauma

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 Threatened abortion
Is a clinical condition that is characterized by vaginal
bleeding before 28 weeks of gestation.

there is crampy lower abdominal pain

• On examination,

 the uterine size is appropriate for gestational age

 the cervix is long and closed

The fetus is alive and there is a chance of continuing the pregnancy

to viability.
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Threatened abortion…… Management
Bed rest at home which could be reinforced by
sedatives like diazepam.

Women who have bled much (regardless of the

gestational age) or have bad obstetric history or live far
away and cannot get help if bleeding becomes much
worse especially during the night should be admitted for
observation.

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Threatened abortion…… Management
Advice on discharge:

To limit her activities for at least 2 weeks and avoid

heavy work.

Avoid intercourse and douching

Monitor progress by subsequent assessment. Where

available ultrasonography.

If there is any sign of pelvic infection evacuation of the

uterus
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should be performed 11
Inevitable Abortion
• Is a clinical condition characterized by vaginal
bleeding of variable amount and crampy lower
abdominal pain.

• The cervix is open but no products of conception

have been expelled

• There is no chance of salvaging the pregnancy

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Inevitable Abortion
• When abortion is imminent
 Painful uterine cramps/contractions
reach peak intensity
 The cervix is dilated to variable
extent

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 Inevitable Abortion Management
A. Less than 14 weeks of gestation:
• Evacuation of the uterus is the mainline of
treatment .
• Evacuation can be done either by sharp metallic
curettage or by manual vacuum aspirator
(MVA).
 MVA is much safer and recent technology.
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 Inevitable Abortion Management
Mandatory indications for evacuation

1. Considerable bleeding

2. Bleeding which continues for more than 24 hours.

3. Patients in whom the retained products of

conception are obviously still present on vaginal
examination.

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 Inevitable Abortion Management
B. More than 14 weeks of gestation
Management includes
Admission and monitoring the vital signs and the amount of
bleeding

 Once the fetus / placenta are expelled completeness should be

checked

Evacuation of the uterus must be done if incomplete or the bleeding

continues.

 Ergometrine or oxytocin as drip is given for continued bleeding

after expulsion or evacuation and monitoring should continue.

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 Incomplete abortion
Is a clinical condition in which

 vaginal bleeding continues and

cervix remains open despite expulsion of part of the

products of conception.

Management

Uterine evacuation should be done preferably by

MVA. Antibiotics as needed can be given.
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 Incomplete abortion management
Uterine evacuation

If uterine size < 14 weeks

 Manual / electrical vacuum aspiration or evacuation and

curettage(E&C)/dilatation and curettage (D&C)if cervix is
closed

• If uterine size > 14 weeks

Oxytocin infusion or evacuation and

curettage(E&C)/dilatation and curettage when appropriate
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 Abortion

Threatened miscarriage Inevitable miscarriage Incomplete miscarriage

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 Complete Abortion
• Is a clinical condition in which

 Product of conceptus completely expelled

vaginal bleeding stops and the cervix closes following

expulsion of all products of conception.

The uterus is small for the duration of the pregnancy

and it is firmer.

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 Complete Abortion
• If completeness is confirmed either by examination of
the conceptus tissue or where available by ultrasound

Administer ergometrine 0.5mg

 If justified provide therapeutic or prophylactic

antibiotics

Evacuation of the uterus must be done if completeness

can not be assured.
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 Missed Abortion
• In-utero death of the embryo or fetus prior to the 20th
week of gestation or before periods of viability

• Regression of symptoms associated with early

pregnancy (eg, nausea, breast tenderness) and they
don't "feel pregnant" anymore

• Vaginal bleeding may occur.

• The cervix is usually closed

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 Missed Abortion management
A. Expectant management up to 4 weeks

 This is based on the fact that 95% women with missed

abortion will abort spontaneously in 4 weeks.

 After 4 weeks the chance of developing disseminated

intravascular coagulation( DIC) is significant.

Monitor coagulation profile weekly.

• Evacuation of the uterus is done if the patient did not expel in

4 weeks or before 4 weeks if coagulation derangement occurs.
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 Missed Abortion management
B. Aggressive management

Evacuation of the uterus by

• dilatation and curettage (D&C) for uterine sizes up to 12

weeks or

• induction of labor by prostaglandins /oxytocin infusion

if uterine size is more than 12 weeks.

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 Septic abortion
• If any of the clinical stages of abortion get infected it
is called septic abortion

• Fever, chills, malaise, abdominal pain, vaginal

bleeding, and malodorous discharge

• Physical examination may reveal tachycardia,

tachypnea, lower abdominal tenderness, and a
boggy, tender uterus with dilated cervix.

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 Septic abortion
• Infection is usually due to staphylococcus aureus, gram
negative bacilli, or some gram positive cocci.

• Mixed infections, anaerobic organisms, and fungi, can

also be encountered

• A common complication of illegally performed

induced abortion

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 Unsafe abortion
Unsafe abortion

persons lacking the necessary skills or in an

environment that does not conform to minimal medical
standards, or both.

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 Recurrent Pregnancy Loss/RPL
• Also called recurrent spontaneous abortion

• Defined as ≥3 consecutive clinically recognized

pregnancy losses

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Recurrent abortion

Etiologies

Parental chromosomal Infectious factors

abnormalities Immunologic factors
Anatomic factors Thrombotic factors
Endocrine factors Others e.g. toxins

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Induced abortion
• Induced abortion is the medical or surgical termination of
pregnancy before the time of fetal viability
• Abortion is called induced when there is a deliberate
interference with the pregnancy for the sake of
terminating it.
• Unintended pregnancy is a problem that may never be
fully resolved, and women who do not wish to continue a
pregnancy will often seek out termination by any means,
regardless of safety
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 Classification of Induced Abortion
1) Therapeutic Abortion

Subset of safe abortion which is performed for the purpose of

saving the life of the mother or if the fetus has congenital /
chromosomal / metabolic disorders that is incompatible with

life after birth. Severe maternal medical disease

Rape
Incest
Fetus with a significant anatomic or mental deformity
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Classification of Induced Abortion
2) Elective (Voluntary) Abortion
At the request of the woman, but not for medical
reasons
One pregnancy is electively terminated for every
four live births in the US
Ethiopia ? ?

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In Ethiopia, Abortion is allowed by law in the
following conditions:
1. When the pregnancy results from rape or incest
2. When continuance of the pregnancy endangers the
health or life of the woman or the fetus;
3. In cases of fetal abnormalities
4. For women with physical or mental disabilities & age
<18 ( ie, For minors who are physically or
psychologically unprepared to raise a child)
5. In the case of grave and imminent danger that can be
averted only through immediate pregnancy
termination
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 Techniques for induced
Abortion
 Surgical methods

 Medical methods

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 i. First trimester pregnancy
A. Surgical method

 Manual vacuum Aspiration (MVA)

Nullipara and gestational age of less than 12 weeks;

priming the cervix with misoprostol 400 mcg vaginal doses and

4-6 hours later MVA may be preferred.

• Procedure is done in the OPD and patient need not be admitted to

hospital.

• Analgesic includes verbacaine and tramadol, declofenac, or

pethidine I.M. 15-30 minutes before procedure
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Induction of abortion in first trimester….
B. Medical Method

• Up to 9 weeks; mifeprisone 200 mg p.o. then 36-48 hours

later misopristol 800mcg vaginal dose and follow-up in a
health institution until 4-6 hours.

• Up to 9 week’s misopristol dose can be sublingual.

• Patient may need admission until misopristol dose

depending on her choice.

• Analgesia include ibuprofen 800mg p.o. every 3-4 hours

after misopristol administration until complete expulsion
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 ii. 13-24 weeks gestational age
A. Surgical Method

 D and E; but preferred method is medical

 For 18-24 weeks D and E with or without cervical preparation

may be done occasionally by a person with the specific skill

 Misopristol 400mcg vaginal dose 4-6 hours later to be followed

by D and E

 Intramuscular analgesics or local or regional anesthesia

 Patient usually require admission to the wards for preparation

and procedure
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ii. 13-24 weeks gestational age abortion….
B. Medical

 Oral mifepristone, 200 mg, followed 24 hours later by vaginal

misopristol, 800 mcg, or

Sublingual misopristol, 600 mcg, with subsequent vaginal,

sublingual or

 Oral misopristol, 400 mcg every 4 hours until expulsion of fetus

or up to five total doses.

Loading dose of misopristol should be decreased by half if GA

is greater than 24 weeks or if there has been a uterine scar.

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ii. 13-24 weeks gestational age abortion….
• After fetal expulsion, give the woman a uterotonic
agent to help the uterus contract;

• Misopristol, 400-800 mcg orally, buccally, sublingually

or rectally.

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If expulsion has not occurred after 24 hours and uterine
rupture has been ruled out, the following may be taken:
• Repeat the original regimen after at least 12 hours of rest
• Rupture the membranes and continue the original regimen
• High dose oxytocin. Adminster 200 units of oxytocin in
500cc of normal saline or lactated ringer solution at 50 cc/h
iv until expulsion or a maximum of 24 hours.
• To avoid water intoxication, stop the infusion for 1 hour out
of every four, and monitor fluid status and urine output
closely.
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 Use controlled cord traction for placental removal,
but apply clamp only on the maternal side of the cord

 If the placenta remains in the uterus, there are a

few options:

• Use buccal, oral or rectal misopristol, 400-800 mcg

• Attempt a sponge-stick expulsion

• If the cord is torn or the placenta cannot be expelled,

MVA or curettage should be performed
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After expulsion of the fetus and placenta;
• Insert a speculum and gently wipe blood clots from the
cervix and visually confirm that there are no lacerations.
• Examine the placenta and fetus to confirm that expulsion
was complete.
• Cover the fetal tissue so it is out of the woman’s sight,
follow local protocols for disposal
• Patient status and presence of complications need to be
assessed every time misopristol is administered, after
expulsion and whenever indicated.
• Po ant pain to be started after misopristol administration
as in
• Patient may need not admission until misopristol
administration if she want
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 iii. 24-28 weeks gestational age
 Oral mifepristone, 200 mg, followed 24 hours later by
vaginal misopristol, 400 mcg every 6 hours until expulsion of
fetus or up to five total doses.

 X (extraction of fetus or total breech extraction) followed

by CCT can done with dilated cervix)

 Generally, complications tend to increase with increasing

gestational age and therefore the attending clinician should be
meticulous about patient evaluation and follow-up.
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Generally, Techniques for induced Abortion includes
1) Surgical techniques

• Cervical dilatation followed by uterine evacuation

Curettage
Vacuum aspiration (suction curettage)
Dilatation and evacuation (D&E)
 Dilatation and extraction (D&X)

• Laparotomy
 Hysterotomy
Hysterectomy
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MVA

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MVA

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2) Medical techniques
 Intravenous oxytocin

 Intra-amnionic hyperosmotic fluid

 Prostaglandins E2, F2?, E1, and analogues

Antiprogesterones (RU 486 [mifepristone] and

epostane)
 Methotrexate (intramuscular and oral)

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Features of Medical and Surgical Abortion

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Complications of abortion
1. Hemorrhage

2. Infection

3. Injury to the genital organs

4. Infertility

5. Chronic adhesions

6. Psychological trauma

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 Comprehensive Abortion Care(CAC)
The Five Elements of Abortion Care

1. Emergency management of abortion and its

complications:
A. Management of incomplete and unsafe
abortion
1. effective pain control
2. evacuation of the uterus
3. provision of orderly post &
preprocedure and discharge
instructions
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Comprehensive Abortion Care(CAC
B. Detection and management of complications of
abortion.

• Hemorrhage

• Sepsis (infection)

• Uterine perforation

• Visceral injury

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Comprehensive Abortion Care(CAC)
2. Post abortion FP
 prevent unwanted pregnancy
 Birth spacing
3. Counseling
 To make free and informed choice
4. Linkage of PAC with other RH services
5. Community provider interaction

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 Post-abortion care
• Identify, manage, and refer for complications as appropriate

• Give discharge instructions

• Give post-procedure counseling, as appropriate, on STDs,

VCT, GBV, contraception, and other issues

• Provide the chosen method of contraception immediately

after abortion, following the WHO eligibility criteria

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Post-abortion care
• Do Pap smear or VIA for all women, whenever
available.

• Provide STD screening, partner tracing, and sexual

health counseling

• Creating partnership with the community as much

as possible

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 Summary of abortion Management
General management
Transfusion if anemic
Anti-D if Rh negative
Specific management depends on the diagnosis
• Threatened
Bed and pelvic rest
• Inevitable
Watch for spontaneous expulsion
• Incomplete abortion
Evacuation by MVA or E & C
• Septic abortion
Broad spectrum antibiotics & evacuation
• Missed abortion
Medical/ surgical management
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