ABORTIONS

AND
POST ABORTION CARE
BY
DR.OKERE RAYMOND

OBGYN DEPT FTH IDO .

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 SESSION OBJECTIVES
⚫ Define abortion.

⚫ Describe the various types of abortion.

⚫ Discuss the causes of abortion.

⚫ Mention the clinical manifestations of abortion.

⚫ Describe the complications of abortion.

⚫ Discuss unsafe abortion and post-abortion care.

⚫ Cervical Incompetence.

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Definitions
⚫ Abortion is defined as termination of
pregnancy, either spontaneously or
intentionally, before the fetus develops
sufficiently to survive.

⚫ Loss of a pregnancy before the age of viability.

⚫ The gestational age at which the fetus is considered

sufficiently developed to survive varies with
regions of the world.
⚫ In Nigeria – 28 weeks
⚫ In the US – 24 weeks
⚫ WHO - 20 -24 weeks
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 Definition (Contd.)
⚫ Improving technology has led to decrease in the age
of viability.
⚫ In Nigeria, it is about 28 weeks which corresponds
to a weight of 1,000gms (1kg) or less.
⚫ WHO Definition: Expulsion or extraction from
its mother of a fetus or embryo weighing <
500 gms.
⚫ This definition excludes those with signs of life at
expulsion.

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Classifications

⚫ Spontaneous (miscarriage)

⚫ Induced

⚫ First or Second Trimester

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Spontaneous Abortion
⚫ Commonest complication of pregnancy
⚫ Incidence:
⚫ 15% -clinical pregnancies
⚫ 60% -chemical pregnancies(early preg b4 uss diag)

⚫ 80% occur prior to 12 weeks gestation

⚫ Very early in the first trimester, the fetus
may be absent and this is called BLIGHTED
OVUM which is technically a form of missed
abortion.

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 CLASSIFICATIONS OF
SPONTANEOUS ABORTIONS

⚫ Threatened
⚫ Inevitable
⚫ Incomplete
⚫ Complete
⚫ Missed
⚫ Recurrent
⚫ Septic
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 CAUSES OF SPONTANEOUS
ABORTIONS

⚫ Genetic abnormalities

⚫ Maternal causes

⚫ Toxic factors

⚫ Trauma

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 Genetic Abnormalities
⚫ 50% - 60% of fetuses expelled
spontaneously contain chromosomal
abnormalities;
⚫ Common in the first trimester
⚫ Autosomal trisomy is the most
frequent abnormality detected.
⚫ In later pregnancies, chromosomal
abnormalities play less role in
causing abortions.
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Genetic Abnormalities(Contd.)
Chromosomal abnormalities
⚫ Common in first trimester abortions
⚫ Aneuploidy (abnormal chromosome
number) accounts for 50% eg.
⚫ Trisomies (most common)
⚫ Turner syndrome
⚫ Second trimester: 20 – 30%
⚫ Third trimester (non abortion losses): 5 – 10%

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Maternal Causes
⚫ Maternal infections
⚫ Malaria
⚫ UTI
⚫ TORCHS syndrome (toxoplasmosis, rubella,
cytomegalovirus, herpes, syphilis, etc.)

⚫ Maternal disease
⚫ Anaemia
⚫ Sickle Cell Disease
⚫ Hypertension
⚫ Diabetes Mellitus
⚫ Malnutrition
⚫ Cardiac disease, etc

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Maternal Causes (Contd.)
Uterine Defects
⚫ Cervical incompetence
⚫ Congenital anomalies
⚫ Previous scarring
(Asherman's syndrome,
myomectomy)
(Usually cause second trimester losses)

⚫ Immunologic
⚫ ABO incompatibility
⚫ Rhesus incompatibility
⚫ Antiphospholipid syndrome
⚫ Systemic lupus erythematosus
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 Toxic Factors
⚫ Alcohol
⚫ Smoking
⚫ Radiation
⚫ Cytotoxic drugs
⚫ TRAUMA
⚫ Direct (gunshot wound to the uterus,RTA,etc)
⚫ Indirect (removal of ovary containing
corpus luteum of pregnancy)

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 A) Threatened Abortion
⚫ Prior history of amenorrhoea
⚫ Minimal painless vaginal bleeding/spotting
⚫ Occasionally lower abdominal
cramping present
⚫ Cervix remains closed
⚫ Ultrasound for fetal viability
⚫ Internal Os assessment
⚫ Reassure/Bed rest
⚫ Abstinence from sexual intercourse
⚫ Repeat ultrasound after 1 week
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Threatened Abortion (Contd.)
⚫ Malaria and UTI are associated in
this environment with threatened
abortion;
⚫ Differentials include ectopic pregnancy
and should be ruled out;
⚫ About half of these will expel the
fetus eventually;
⚫ Demonstration of fetal echo at the time
of diagnosis is associated with
favourable outcome.
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B) Inevitable Abortion
⚫ A threatened abortion becomes
inevitable when there is:
⚫ Presence of abdominal cramps which
may be radiating to the back;
⚫ Increasing bleeding;
⚫ Dilatation of the cervix;

⚫ In more advanced pregnancy, loss of

amniotic fluid in the presence of a pre-viable
fetus is considered inevitable abortion.

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 Inevitable Abortion (Contd.)

Management
⚫ Full Blood Count
⚫ Group/crossmatch blood
⚫ Relieve pain
⚫ Give oxytocics to accelerate
abortion process (if contracting)
⚫ Manual vacuum aspiration
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C) Incomplete Abortion
⚫ Incomplete abortion is evidenced by
continued increasing bleeding following
expulsion of products of conception
⚫ The cervical os is almost invariably open
⚫ There is usually abdominal pains as the
uterus attempts expulsion of the products
of conception.
⚫ Investigations
⚫ FBC; + Ultrasound
⚫ Group/crossmatch blood
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Management principles of
incomplete abortion
⚫ History
⚫ LMP
⚫ WHO, WHEN,WHERE and HOW performed
⚫ Possible complications
⚫ PE
⚫ Resuscitate and Stabilise patient
⚫ Relevant investigations (PCV, USS, Bld grp,etc)
⚫ IV fluids
⚫ Antibiotics, anti-tetanus,anti-D immunoglobulin
⚫ Evacuation when stable
⚫ Specimen for histology and follow-up
⚫ Counselling and contraception .
Incomplete Abortion (Contd.)
Management
⚫ Resuscitate
⚫ Oxytocics
⚫ Ergometrine
⚫ Oxytocin

⚫ Evacuate uterus (Manual

Vacuum Aspiration)
⚫ Anti-D Gammaglobulin for Rh (D)
negative women
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KARMAN’S SYRINGE

⚫Karman’s Syringe
(Used for Manual
Vaccum
Aspiration, MVA)

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 Rationale for Using Manual Vacuum
Aspiration (MVA)

MVA is the preferred treatment

of incomplete abortion
because:
⚫ risk of post-evacuation complications
is reduced,
⚫ cost of post-abortion services and
resources used are reduced - reusable
equipment
⚫ Emergency post-abortion care can be
provided at remote sites (small clinics)
not just in urban centers
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D) Complete Abortion
⚫ Complete expulsion of products of conception

⚫ Absent/minimal bleeding

⚫ No more pain

⚫ Cervix is closed

⚫ USS confirms empty uterus

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E) Septic Abortion
⚫ Evidence of infection together
with incomplete abortion
⚫ Pyrexia
⚫ Rigors
⚫ Abdominal pain
⚫ Odorous vaginal discharge

⚫ Predisposing factors
⚫ Induced abortion
⚫ Retained products of conception
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Septic Abortion (Contd.)
Investigations

⚫ Full Blood Count

⚫ Clotting profile

⚫ Septic work up/screening

⚫ Electrolytes and Urea

⚫ Abdomino-pelvic USS

⚫ + X - ray
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Septic Abortion (Contd.)
⚫ Septic abortion usually follows
incomplete abortion
⚫ Could be a life-threatening condition
⚫ Requires evacuation
⚫ Septic uterus is soft - Easier to perforate
⚫ Give oxytocics to contract uterus
⚫ Give antibiotics for at least 6 hours
before evacuation
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Septic Abortion – Management
⚫ Life threatening condition
⚫ Review by senior colleagues
⚫ Multi – disciplinary management
⚫ General Surgeons
⚫ Physicians
⚫ Anaesthetists

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 Management of Septic Abortion (Contd.)
⚫ Oxytocin drip
⚫ Resuscitation
⚫ I/V fluid; Blood transfusion and
keep a Fluid chart
⚫ Antibiotics (Triple Regimen)
⚫ Cover anaerobic and aerobic organisms
⚫ Tetanus prophylaxis
⚫ Analgesics
⚫ Post-evacuation: Contraceptive counselling
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Complications of septic Abortion
Early/Immediate
⚫ Peritonitis
⚫ Pelvic/intra-abdominal abscess
⚫ Haemorrhage
⚫ Coagulation failure
⚫ Deaths : (Unsafe abortion)13% of
maternal deaths

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Long-term complications of septic
Abortion

⚫ Chronic pelvic pain

⚫ Chronic PID
⚫ Ectopic pregnancy
⚫ Infertility
⚫ Asherman's syndrome

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F) Missed Abortion
⚫ This is said to occur when a dead
product of conception is retained behind
a closed cervical os
⚫ Women usually report regression
of symptoms of pregnancy
⚫ The uterus is usually smaller than
the corresponding gestational age
⚫ Negative pregnancy test
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Missed Abortion(Contd.)
Pregnancy is retained following fetal death

Blighted Ovum (Anembryonic pregnancy)

- Embryo dies and is resorbed
- USS shows gestational sac without fetal echoes

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Missed Abortion (Contd.)
⚫ Ultrasound Scan (USS):
⚫ irregular gestational sac without
fetal echo
⚫ Intra-uterine death
⚫ Femur length indicates point of demise

⚫ Coagulopathy is more
commonly associated with
missed abortion compared to
others
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 Missed Abortion - Management

⚫ Risk of coagulation failure

⚫ Check clotting time and platelet count
⚫ Group/cross match blood
⚫ If ≤ 12 weeks perform manual
vacuum aspiration
⚫ > 12 weeks: induce with
prostaglandins followed by oxytocin
⚫ May occasionally require hysterotomy
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G) Recurrent Abortions
⚫ Defined as 3 or more consecutive
pregnancy losses before age of viability
⚫ Risk of miscarriage rises to 25 – 50% after 3
or more miscarriages
⚫ Also called Habitual abortion
⚫ Causes include:
⚫ Genetic
⚫ Uterine abnormalities
⚫ Hormonal
⚫ Other Causes
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 Causes of Recurrent Abortions
⚫ I )Genetic
⚫ Paternal : corrected by Donor Insemination
⚫ Maternal : ovum donation
⚫ Pre-implantation diagnosis

⚫ II)Hormonal Causes
⚫ Thyroid disease
⚫ Diabetes mellitus
⚫ Luteal phase defect
⚫ Faultyendometrium causing faulty
implantation

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 Causes of Recurrent Abortions(cont’d)
(III) Uterine Abnormalities
⚫ Congenital uterine abnormalities
⚫ Cervical incompetence
⚫ Sub-mucous fibroids
⚫ Asherman’s syndrome
⚫ Losses usually occur in second trimester
Mechanisms:
⚫ Interferencewith implantation
⚫ Inadequate blood supply

⚫ Growth restriction

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Uterine Abnormalities
Diagnosis
⚫ Hysterosalpingography
⚫ Hysteroscopy
Treatment
⚫ Surgical

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IV) Other causes of recurrent
abortion
⚫ Infections
⚫ Immunologic factors
- Antiphospholipid antibodies
- Lupus anticoagulant
- Anticardiolipin antibodies
Treatment : low dose aspirin/Heparin

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 H) Induced Abortion
⚫ A)Therapeutic
⚫ B)Criminal/illegal
⚫ This is medical or surgical termination of
pregnancy before the time of fetal
viability.

⚫ There are a few therapeutic indications

⚫ In Nigeria, majority are criminal or illegal

⚫ Most are unsafe abortions

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Reasons for Induced Abortions

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 Induced Abortions –
Surgical Methods

⚫ Dilatation and Curetage (not recommended)

⚫ Dilatation and Evacuation

⚫ Hysterotomy

⚫ Hysterectomy

⚫ Manual Vacuum Aspiration (MVA)

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 Induced Abortions –
Medical Methods

⚫ (By several Routes of Administration)

⚫ Intravenous Oxytocin
⚫ Hyperosmolar Glucose
⚫ 30% Urea
⚫ 20% Saline
⚫ Misopristol
⚫ Mifepristone
⚫ Methotrexate
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Complications of Abortion

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 Long-term Complications of Abortion

⚫ Chronic pelvic pain

⚫ Chronic PID

⚫ Ectopic pregnancy

⚫ Infertility

⚫ Asherman’s syndrome

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 UNSAFE ABORTION
⚫ Clandestine termination of pregnancy due to
1.Restrictive abortion laws
2.Lack of access to contraceptives (unmet need)
3.Judgmental attitude of the society
⚫ Abortion is induced illegally medically
or surgically.

⚫ Usually complicated due to the use of unhygienic

methods.

⚫ Commonest cause of mortality among

adolescents.
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UNSAFE ABORTION
⚫ “Unsafe abortion” is defined by WHO as
‘a procedure for terminating unwanted
pregnancy either by:
⚫ persons lacking the necessary skills or
⚫ in an environment lacking the
minimal medical standards’
⚫ Or both of the above.
⚫ Of note “unsafe” is not a synonym for
‘illegal’ or clandestine, e.g., legal abortion
may be unsafe because of poorly trained
clinicians, or inadequate facilities or
both.
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POST-ABORTION CARE (PAC)
⚫ Post abortion care consists of emergency
health care services, family planning counseling
and referral services offered to a woman as a
result of complications arising from an induced
or spontaneous abortion.

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Post–abortion care (PAC)
Morbidity/mortality from unsafe abortion is due to
lack of access/delayed treatment.
PAC includes:
⚫ Early identification/diagnosis of complications
⚫ Early resuscitation and treatment including referral
⚫ i/v fluids
⚫ Oxytocis
⚫ Antibiotics
⚫ MVA
⚫ Referral
⚫ Linkage with other RH services
⚫ Family planning
⚫ Infertility
⚫ Cervical cytology
⚫ HIV / AIDS services,etc.

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PAC
⚫ Elements
A. Treatment of incomplete abortion and
abortion- related complications that are
potentially life threatening
B. Counselling to identify and respond to
women’s emotional and physical health needs
and other concerns
C. Provision of contraceptives and family
planning services
D. Reproductive and other health services
E. Linkage with community
 ELEMENTS OF POST-ABORTION
CARE

⚫ Emergency treatment of incomplete abortion

and potentially life-threatening complications

⚫ Post-abortion FP counseling and services

⚫ Links between post-abortion emergency services

and the reproductive health care system

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 o Care
Elements of Post-ab rtion

Emergency
FP Counseling
Treatment
& Services

Other
Reproductive
Health Services
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 Need for Post-abortion FP Services

⚫ Unsafe abortion is a prime indicator of unmet

need for FP

⚫ Failure to provide FP is a major contributor to

the problem of unsafe abortion

⚫ Emergency treatment is not linked to

FP counseling or services

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Prevention of unsafe abortion
⚫ Primary
⚫ Provision of RH information and services
⚫ Provision of quality sexuality education
⚫ Provision of family planning methods
⚫ Improved access to adolescents
⚫ Secondary
⚫ Counseling for women with unwanted pregnancy
⚫ Tertiary
⚫ Treatment for women with complications of unsafe
abortion

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Breaking the cycle of repeat unwanted
pregnancy and unsafe abortion
Postabortion Contraception

Contraceptive non-use, non-

availability or failure; Emergency abortion
involuntary or unplanned sex care

Unsafe abortion
Unwanted or high-risk
pregnancy

Restricted access to safe

abortion services

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Cervical incompetence
⚫ Most common cause of recurrent abortion in
Sub – Saharan Africa
⚫ Inability of the cervix to support a
pregnancy to term due to structural and
functional defect.
⚫ Typical history : recurrent mid-
trimester abortions
⚫ Painless rupture of membrane
⚫ Bleeding/expulsion of products of conception in
mid/early third trimester

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Causes of cervical
incompetence
⚫ Previous forceful dilatation of cervix
⚫ Previous surgery
⚫ Amputation of cervix (Manchester repair)
⚫ Cone biopsy
⚫ Cervical laceration at childbirth
⚫ Congenital weakness
⚫ In-utero exposure to DES

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Diagnosis
⚫ History is typical
⚫ During pregnancy examination:
⚫ Dilated cervix
⚫ Bulging membranes
Ultrasound
⚫ Assess cervical os diameter and cervical length
⚫ Non – pregnant state
⚫ HSG: Funnel – shaped uterus
⚫ Retrograde cervical dilatation beginning with size 10
Hegar’s dilator.
⚫ Insert Paediatric Foley’s catheter ; apply traction after
inflation
⚫ Extraction diagnostic

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Management
⚫ Encourage woman to conceive
⚫ Confirm normal pregnancy in first trimester
⚫ Insert a cervical cerclage between 14 and
18 weeks
⚫ MacDonald suture
⚫ Shirodkar suture
⚫ Employ mersilene tape (non-absorbable tape)
⚫ Suture knotted posteriorly
⚫ Trans-abdominal cervical cerclage
⚫ Short cervix
⚫ Failed cerclage
⚫ Suture removed at 38 weeks
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Indications for removal prior to 38 weeks
⚫ Ruptured membranes
⚫ Ante – partum haemorrhage
⚫ Intra – uterine infection
⚫ Congenital malformation
⚫ Intra – uterine death
⚫ Pre-term contractions

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CONCLUSION
⚫ Abortion is a major cause of maternal morbidity
and mortality.
⚫ Life threatening complications arise from
abortions.
⚫ Abortion and its complications require urgent
management.

⚫ Counseling and provision of family planning

methods are essential.

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THANKS FOR THE ATTENTION

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