ABORTION AND POST-ABORTION CARE

Namus
NamusM.M.
Sep 2021
Sep 2021
OUTLINE
OUTLINE
 Introduction
 Definitions
 Risk factors
 Etiology
 Clinical manifestation
 Induced abortion
 Post Abortion care
 References
INTRODUCTION
INTRODUCTION
 Abortion, whether spontaneous or induced, is one of the most common obstetric events in the world,
second only to childbirth.

 46,000,000 women around the world have induced abortions each year, 78% of whom live in developing
countries and 22% of whom live in developed countries.

 Where abortion is legally permitted, safe and available, complications are rare.

 In countries where provision of abortion is restricted, women often resort to unsafe methods that result in
complications, long-term health problems or even death.
INTRODUCTION
INTRODUCTION
 61% of the world’s women live in parts of the world that permit abortion for broad indications;

 many of the rest live in countries that allow abortion on at least some grounds, for example to save the
life of the woman

 Therefore, making safe, effective and acceptable abortion services available and accessible is a critical
component of meeting women’s health care needs.

 Linking abortion to other reproductive health services, including contraceptive counseling and provision,
is essential
DEFINITION
DEFINITION
 Abortion is termination of pregnancy before Viability
 In USA abortion is defined as termination of pregnancy at GA of less than
20 weeks or a birth weight of less than 500gm
 Most Countries abortion is defined as termination of pregnancy before GA
28 weeks or birth weight of less than 1000gm
CLASSIFICATION
CLASSIFICATION
 It is based on :
 Cause
 Gestational Age
 Site of termination
 Legality
 Clinical stage & Presentations
CLASSIFICATION
CLASSIFICATION(CAUSE)
(CAUSE)
 spontaneous abortion:- termination of pregnancy because of natural causes
 Induced abortion:- intentional termination of pregnancy for medical or other
indications
CLASSIFICATION
CLASSIFICATION(GA)
(GA)
 Early abortion
 < 12 weeks
 Late abortion
 >12 weeks
CLASSIFICATION
CLASSIFICATION(SITE
(SITEOF
OF
MX)
MX)
 Safe abortion:-
 when the abortion is done by Skilled person with appropriate methods and in a
clean environment
 Unsafe abortion:-
 terminating pregnancy either by persons lacking the necessary skills or in an
environment lacking the minimal medical standards
CLASSIFICATION
CLASSIFICATION(LEGALITY)
(LEGALITY)
 Legal abortion
 The pregnancy is a result of rape or incest; or
 The continuation of the pregnancy endangers the life of the mother or the child or
the health of the mother or where the birth of the child is a risk to the life or health
of the mother; or
 The fetus has an incurable and serious deformity; or
 The pregnant woman, owing to a physical or mental deficiency she suffers from or
her minority, is physically as well as mentally unfit to bring up the child.
 Illegal abortion
CLASSIFICATION
CLASSIFICATION(CLINICAL
(CLINICAL
STAGE)
STAGE)
 Threatened Abortion
 Inevitable Abortion
 Incomplete Abortion
 Complete Abortion
 Missed Abortion
 Septic Abortion
 Recurrent (Habitual) Abortion
 THREATENED
THREATENEDABORTION
ABORTION
 The bleeding is not usually severe
 The cervical os is found to be closed
 Minimal Uterine cramping and pain; occasionally lower abdominal pain and
backache.
 The membrane remains intact and no tissue is passed.
 Approximately 25% women exhibit signs of threatened abortion
and 60-80% continue the pregnancy
 INEVITABLE
INEVITABLEABORTION
ABORTION
 When it is impossible for the pregnancy to continue it is termed as
inevitable abortion
 Profuse vaginal bleeding
 The abdominal pain becomes more acute and rhythmic in character
 Open cervix but no expulsion of conceptus leakage of liqour
 INCOMPLETE
INCOMPLETEABORTION
ABORTION
 Uterine bleeding with cervical dilation but with incomplete expulsion of the
POC
 Bleeding is profuse it can cause hemodynamic instability
 COMPLETE
COMPLETEABORTION
ABORTION
 Complete expulsion of all conceptus parts which are identified by provider
including the fetus, placenta, membranes and cord
 Uterus well contracted and cervix closed
 Cessation of vaginal bleeding
 MISSED
MISSEDABORTION
ABORTION
 Embryonic demise without expulsion of POC and with closed cervical os
 Initial symptoms of abortion subside with cessation of vaginal bleeding and
uterine contractions
 Regression of symptoms and signs of pregnancy
 Retention of conceptus within the uterus for more than two weeks
 SEPTIC
SEPTICABORTION
ABORTION
 Any of the abortion types complicated by infection
 Headache and nausea accompanied by sweating and shivering and shivering
 Her skin will be hot to the touch and it may be clammy.
 Spiking pyrexia
 Steadily rising pulse
 uterine tenderness
 Offensive vaginal discharge
 RECURRENT
RECURRENT(HABITUAL)
(HABITUAL)ABORTION
ABORTION
 No agreed definition!!!!!!!
 Defined as >/= 3 clinically recognized pregnancy losses before viability
 Most women with recurrent miscarriage have embryonic or early fetal loss,
 being much less common after 14 weeks
 The risk of subsequent loss after two successive miscarriages is similar to
that following three losses—approximately 30 %
RISK
RISKFACTORS
FACTORS
 Age:- advanced maternal Vs trisomic abortions
 Previous spontaneous abortion : 20% recurrence rate
 Smoking : euploid ab, dose related, >14 cigar_ 1.7x risk of SAB
 Alcohol : 1st 8 wks, high and frequent doses
 Increased parity, maternal and paternal ages… independent risk factors
 Surgery : Oophorectomy or removal of CL IF < 10 WKS
 Contraceptives (IUCD failure)
RISK
RISKFACTORS
FACTORS
 Fever :
 Caffeine : slight increase if > 5 cups/ day
 Low folate level :
 Radiation : therapeutic doses, lower doses not studied
 Maternal weight : sign. wt loss even in hyperemesis is rarely asso with ab
 Celiac disease : increase spont. Ab and both male and female infertility
 DM (TYPE 1 & 2 , increase the risk of major anomalies and sp. Ab if …..)
 Paternal ???? Age
ETIOLOGIES
ETIOLOGIES
 An abnormal karyotype is present in approximately 50% of spontaneous abortions <12
weeks , Other causes like infection, anatomic defects, endocrine factors, immunologic
factors, and maternal systemic diseases account for a smaller percentage.
 Significant percentage of spontaneous abortions, the etiology is unknown
 But there are 3 major causes:-
 Fetal
 Maternal
 Paternal
FETAL
FETALCAUSES
CAUSES
 50-60% is due to chromosomal abnormalities
 Aneuploidy (an abnormal chromosomal number) is the most common
genetic abnormality
 Trisomy: 50%
 Polypoid: 20%
 Monosomy for chromosome X: 18%
 Unbalanced translocations: 4%
MATERNAL
MATERNALCAUSES
CAUSES
 congenital or acquired uterine abnormalities (eg, uterine septum, submucosal leiomyoma,
intrauterine adhesions) can interfere with optimal implantation and growth accomodation
 Acute maternal infection with any of a large number of organisms
 Brucella abortus, campylobacter fetus in cattle, not in human
 Listeria monocytogenes (no evidence)
 Toxoplasma gondii, (inconclusive)
 parvovirus B19, rubella, herpes simplex, ????
 cytomegalovirus, lymphocytic choriomeningitis virus can lead to abortion from fetal or placental
infection.
MATERNAL
MATERNALCAUSES
CAUSES
 Maternal endocrinopathies
 thyroid dysfunction
 Cushing's syndrome,
 polycystic ovary syndrome can also contribute to a suboptimal host
environment.
PATERNAL
PATERNALCAUSES
CAUSES
 Chromosomal translocations in sperm
 similar maternal and paternal human leukocyte antigen (HLA)
CLINICAL
CLINICALMANIFESTATION
MANIFESTATION
AND
ANDDIAGNOSIS
DIAGNOSIS
 History of
 amenorrhea
 vaginal bleeding, and
 pelvic pain.
 On examination,
 cervix is open and
 products of conception can be visualized in the vagina or cervical os, if they have not already
been passed.
 DIFFERENTIAL
DIFFERENTIALDIAGNOSIS
DIAGNOSIS
 Physiologic (ie, believed to be related to implantation)

 Ectopic pregnancy

  Impending or complete miscarriage

 Cervical, vaginal, or uterine pathology

DIAGNOSTIC
DIAGNOSTICWORKUP
WORKUP
 Hemoglobin ( hematocrit)
 Blood group and RH type
 Pregnancy test if necessary
 Ultrasonography ( empty gestational sac, fetal disorganization, lack of fetal growth)
 Blood cross match if necessary
 In cases of septic abortion
 WBC and differential
 Coagulation profile
INDUCED
INDUCEDABORTION
ABORTION
 Induced abortion is a controversial topic that ignites complex and
emotional debate.
 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.
 Clinical guidelines were prepared with the best available evidence and
professional consensus on induced abortions.
 DEBATE
DEBATE
I
 WHY
WHYTHE
THECONTROVERSIES??
CONTROVERSIES??
 Ethical issue
 Personhood
 Deprivation
 Bodily rights
 Social issues
 Sex selective abortion
 Unsafe abortion
 Religious views
ETHICS
ETHICS
 Ethics discusses what one "ought" to do or what should be legal, rather
than the law itself.
 Regarding abortion, the ethics debate usually surrounds the questions of
whether an embryo has rights, and whether those rights should take
IMPORTANCE over a woman's right and life
 For many, there is a strong correlation between religion and abortion ethics
PERSONHOOD
PERSONHOOD
 Some argue that abortion is wrong based on a belief that an embryo is an
innocent person with a right to live ? ? ?
DEPRIVATION
DEPRIVATION
 Some argue that abortion is wrong because it deprives the embryo of a
valuable future

 Thus, if a being has a valuable future ahead of it—a "future like ours"—
then killing that being would be seriously wrong
BODILY
BODILYRIGHTS
RIGHTS
 Some argue that abortion is right (or permissible) because it allows a woman her right to
control her body.

 This formulation argues that the decision to carry an embryo to term falls within the
prerogative of each woman.

 Forcing a to continue an unwanted pregnancy is made analogous to forcing one person's

body to be used as a dialysis machine for another person suffering from kidney failure.
SEX
SEXSELECTION
SELECTION
 The advent of both sonography and amniocentesis has allowed parents to
determine gender before birth.

 The preference for male children is reported in many areas of Asia

RELIGIOUS
RELIGIOUSVIEW
VIEW
 Generally against induced abortion.
CLASSIFICATION
CLASSIFICATIONOF
OFINDUCED
INDUCED
ABORTION
ABORTION
 Therapeutic Induced Abortion
 Elective (Voluntary) Abortion
 THERAPEUTIC
THERAPEUTICINDUCED
INDUCEDABORTION
ABORTION
 persistent cardiac decompensation
 severe diabetes with poor glycemic controle
 advanced hypertensive vascular disease
 invasive carcinoma of the cervix
 rape
 Incest
 fetus with a significant anatomic or mental deformity
 IUFD
 ELECTIVE
ELECTIVE(VOLUNTARY)
(VOLUNTARY)ABORTION
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 ? ? ? ? ? . . . .
 LOCAL
LOCALLAWS
LAWS

I
ARTICLE
ARTICLE524
524
 The intentional termination of pregnancy at whatever stage or however
effected is punishable, except otherwise provided under article 551

 The nature and extent of the punishment shall be determined according to

whether it is procured by the pregnant woman herself or by others, in the
later case whether the woman has gave informed consent or not.
ARTICLE
ARTICLE551
551
 Abortion is allowed under the following circumstances:
 When the pregnancy results from rape or incest
 When continuance of the pregnancy endangers the health or life of the woman or
the fetus;
 In cases of fetal abnormalities
 For women with physical or mental disabilities & age <18
 For minors who are physically or psychologically unprepared to raise a child;
 In the case of grave and imminent danger that can be averted only through
immediate pregnancy termination.
PRE-PROCEDURE
PRE-PROCEDURECARE
CARE
 Counseling and informed decision making
 Diagnosis of pregnancy
 Exclude extra-uterine pregnancy
 Assessment of gestational age
 Cervical Preparation
 Nulliparous women
 Young aged (18 or below) with gestational duration of more than 9 weeks
 All pregnant women with gestations more than 12 weeks.
ABORTION
ABORTIONCARE
CAREPROTOCOLS
PROTOCOLS
 Initial assessment  Contraceptive services
 Counseling  Links to other reproductive health
 Pain management services
 Infection prevention  Discharge and follow-up

 Clinical procedures  Recordkeeping and administration

 Emergency protocols
 Post-procedural treatment
POST
POSTABORTION
ABORTIONCARE
CARE
 Post abortion care (PAC) is a medical service and related interventions
designed to manage incomplete unsafe abortions and its complications.
 PAC has 5 Components.
 POST
POSTABORTION
ABORTIONCARE
CARE
 Community-service provider partnership
 Counseling
 Emergency treatment of incomplete abortion and its complications
 FP services
 Linkage with other RH services
.