ABORTION

At the end of this session the students should able to:

Define abortion
Mention the risk factors for an abortion
Describe the potential DDX
Mention the diagnostic work up and their
interpretation.
Manage patients with abortion.

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 Definition
 Abortion is expulsion of the products of conception
or termination of pregnancy prior to viability of the
fetus.
There are two approaches of abortion definition
1. British approach
Abortion is termination of pregnancy before 28 weeks
of gestation or fetal weight less than 1000gm.
2. WHO approach
Abortion is termination of pregnancy before 20 weeks
of gestational age or fetal weight less than 500 gm.

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Types of abortion based on etiology

• Spontaneous
• Induced
Spontaneous abortion- defined as the loss of a fetus during pregnancy
due to natural causes,before fetal development has reached( 28
weeks).The term spontaneous abortion refers to naturally occurring
events, not elective or therapeutic abortion procedures.

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 Induced abortion
-therapeutic (legal)
-criminal (illegal)
or
-safe
-unsafe

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Cont…

Unsafe abortion:-is characterized by lack or inadequate skill of the

provider, hazardous technique and unsanitary facilities or both.
Therapeutic:- induce pregnancy for the sake of treating and for saving
the life of the mother and conducted intentionally or
termination of pregnancy before the time of fetal viability for the
purpose of saving the life of the mother.

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 Based on Clinical features(stages)or signs
and symptoms

Threatened abortion
o slight intermittent bleeding with or without cramping less than a
week.
o The cervix remains closed and no cervical effacement.
o At least 20–30% of pregnant women have some first-trimester
bleeding.
o In most cases, this is thought to represent an implantation bleed.
o More than 50-80% go to term
o Positive FHB

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 Management

• Complete bed rest & pelvic rest to stop bleeding and avoiding
strenuous exercise.
• Frequent follow up and assessment.
• Anti-pain for lower abdominal pain.
• Advice to avoid sexual contact and douching.
• Assure that 80% of pregnancy can continue until term.
• Prognosis is good when bleeding and/or cramping resolve.

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 Inevitable abortion

 The cervix has dilated, but the products of conception have not
been expelled.
 Sever lower abdominal or back pain and mild to severe vaginal
bleeding.
 cervical effacement, cervical dilatation, and/or rupture of the
membranes is noted.
 It is Irreversible

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management

• According to gestational age

<12 weeks MVA
>12weeks oxytocin infusion and
E/C with pethdine or sedative.

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 Incomplete abortion

• Some, but not all, of the products of conception have been passed,
retained products may be part of the fetus, placenta, or
membranes.
• In gestations of less than 10 weeks duration, the fetus and
placenta are usually passed together. After 10 weeks, they may be
passed separately, with a portion of the products retained in the
uterine cavity.

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Sign and symptoms

• Cramps are usually present

• opened cervix
• ruptured membrane
• Painful, profuse /excess and persistent vaginal bleeding
• there is uterine contraction
• HX of passing conceptus tissue
• Sometimes visible or palpable concepts tissue through the opening cervix
Complications
Anemia, hemorrhage and infection.
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 Management
• Evacuation based on gestational age
• Uterotonic agents
• if she is anemic treat anemia if necessary blood transfuse
• Fluid replacement
• Antibiotic with broad spectrum antibiotics IV or Im route.
• The prognosis for the mother is excellent if the retained tissue is
promptly and completely evacuated.

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 Missed abortion

Def. a pregnancy in which there is a fetal demise (usually for a number of

weeks) but no uterine activity to expel the products of conception
 Regress sx/s of pregnancy
 Uterine size decreased
 cervix closed
 Brownish vaginal discharge
 Negative fetal heart rate

Complications
Infection, DIC, AF embolism.
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Treatment/ management

Expectant management
-3-4 weeks follow up
-Clotting profile
>12weeks
-Prostaglandin or balloon catheter to dilate
cervix
-Pitocin
<12 weeks :-MVA or D/c

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Treatment of complication

Managed accordingly
• laparotomy are indicated to determine the extent of laceration or
bowel injury.
• Broad spectrum antibiotics for sepsis.

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 Complete abortion

• All products of conception have been passed without need for

surgical or medical intervention.
• Slight bleeding may continue for a short time
• pain usually ceases after pregnancy has traversed the cervix.
Management
• observed for further bleeding.
• The products of conception should be examined.
• prognosis for the mother is excellent.

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Recurrent spontaneous abortion

• Defined as 3 or more consecutive, spontaneous pregnancy losses

before 28 weeks of gestation from the last menstrual period , by the
same partner , each with a fetus weighing less than 1000 g.
• Approximately 1% of women are habitual aborters.
• The risk of having a spontaneous abortion for the first time is about
15%, and this risk is at least doubled in women experiencing recurrent
abortion

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 Etiology

Three generally accepted etiologies of recurrent miscarriages are:

• Chromosomal abnormalities
• uterine malformations
- bicornuate or septate uterus
- cervical incompetence
• Immunologic Factors
-Antiphospholipid antibodies.

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 Other etiology

• sub mucous myomas

• Hormonal causes like hyper and hypothyroidism
• Infection
• Maternal system disease e.g. diabetes
• Chronic malnutrition
Septic abortion
• any of abortion complicated by sepsis or when any of the stage of
abortion complicated by pelvic infection, we call it septic abortion.

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 Characterised as
• fever
• bad odor vaginal discharge
• restless
• sign of toxic shock syndrome
• shivering
• abdominal pain
• low blood pressure

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• tachycardia
• tachypnea
• rebound tenderness
• guarding
• cervical excitation tenderness
• adnexal tenderness

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 Investigation

• CBC
• Hgb
• HCT
• ABO grouping
• Rh status
• Blood film
• Abdominal X-ray
• Pelvic X-ray
• U/S
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 Management
• Intravenous Antibiotics administration
• Removing conceptus tissue
• Monitor vital sign
• Anti D (50 ug) for Rh –ve
• TAT
• Anti-coagulant drug if there is DIC

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Mgt…
• Last option is hysterectomy:-during
Uterine perforation
 Gangrene uterus
Unsatisfactory response for ABCs
Pelvic abscess
 Longstanding infection

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 Complications

• Severe or persistent hemorrhage life threatening.

• Sepsis develops most frequently after self-induced abortion.
• Intra abdominal injury
- Perforation of the uterine wall
- injury to the bowel and bladder

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Cont…

• Multiple pregnancy with the loss of 1 fetus and retention of another

("vanishing twin").
• Other complications of abortion
 Anemia
Renal failure
Infertility(if hysterectomy done due to complication)

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 Possible Psychological Effects
• Possible feels after having
an abortion
– Guilt
– Depression
– Negative feelings about sex
– Relationship may end
– Anger
– Bitterness

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 Prevention

• Early obstetric care

• Treatment maternal disorders like diabetes and hypertension
• Protection of pregnant women from environmental hazards and
exposure to infectious diseases.

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Laboratory investigations

• Blood type and RH factor

• Complete blood count
• HCG to confirm pregnancy
• WBC and differential to rule out infection

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 General management

first-trimester loss
MVA ,E&D or D&C
After the first trimester
• hospitalization should be considered
• Oxytocics are helpful in contracting the uterus, limiting blood loss,
and aiding in expulsion of clots and tissue.

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 Cont…

• Anti D for RH negative

• Surgical evacuation
-Patient is unstable:-Heavy bleeding
-Septic abortion
• Medical therapy
 Missed spontaneous abortion
• Expectant management
• Completed spontaneous abortion
• Incomplete spontaneous abortion??

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Induced abortion

Induced abortion is the medical or surgical termination of pregnancy

before the time of fetal viability. it can be legal or illegal, therapeutic
(safe) or un safe( septic ).
septic or Unsafe abortion defined by WHO:
“. . .any procedure for terminating an unwanted pregnancy (carried
out) either by persons lacking the necessary skills or in an
environment lacking minimal medical standards, or both . . .”

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Post abortion care

PAC is an approach for:-

 Reducing morbidity and mortality from complications of unsafe
and spontaneous abortion, and
 improving women’s sexual and reproductive health and lives.

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 Essential Elements of Post abortion Care

1. Treatment
• Treat incomplete and un safe abortion and potentially life threatening
complications.
2. Contraceptive and family planning services
Help women prevent unwanted pregnancy or practice birth spacing.
3. create link with Reproductive and other health services
• Preferably provide on - site, or via referrals to other accessible
facilities in provides’ networks.

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Cont…

4. create link with Community and service provider partnerships

• Prevent unwanted pregnancies and unsafe abortion.
Mobilize resources to help women receive appropriate and timely care
for complications from abortion.
5. Counseling
• Identify and respond to women's emotional and physical healthy
needs and other concerns

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 COMPREHENSIVE ABORTION CARE
(CAC)

• It is an approach for reducing morbidity and mortality from

incomplete, unsafe and safe & legal abortion and resulting
complications and for improving women sexual and reproductive
health and lives.
COMPENENTS OF CAC
There are six element of CAC.
• All components of PAC
plus
• Provide safe, legal abortion service.
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 Legalization /revised law of abortion in
ETHIOPIA
Termination of pregnancy (TOP) by a recognized
medical institution within the period permitted by
the profession is not punishable where:
1. Pregnancy results from rape
2. Pregnancy results from incest/relative

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Legalization…..
3. Continuation of pregnancy endangers the life of mother or the child
or the health of the mother or where the birth of the child is a risk to
the life and health of mother.
4. The fetus has an incurable and serious deformity
5. The pregnant women owing to physical or mental deficiency or unfit
to bring up the child.

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 Medication abortion

Definition :
Is termination of pregnancy ,drug used to induced the pregnancy
with out use of surgical evacuation.
Medical Abortion : Drugs used
 Mifepristone
 Misoprostol

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Regimes for Medication Abortion (MA)

Less than 9 weeks

Day 1 - Mifepristone… 200mg (1 tab) orally
Day 3 - Misoprostol… 800 micro gram (4 tabs) vaginal

9-12 weeks
Day 1 - Mifepristone 200mg orally
Day 3 - Misoprostol 800 mcg vaginally, then misoprostol 400mcg
vaginal or sublingual every 3h hours for a total of four doses.

40
Incomplete abortion

• First trimester incomplete abortion

-single dose 600mcg oral ,91- 99 % success no need of surgical
evacuation.
or
-Single dose 400mcg sublingual 95%.

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 Manual vacuum aspiration(MVA)
Evacuation of content of the
uterus using a flexible cannula
and syringe
Parts of MVA:
• MVA Cylinder
• Valve
• MVA aspirator: MVA cylinder
and valve together
• Cannula
• Selection of cannula depends
on gestational age (n-1) and
cervical dilatation

42
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 Indications and contraindication of MVA
Indication
• Intended for uterine aspiration or evacuation
• Treatment of incomplete abortion up to 12 weeks

• First-trimester abortion (menstrual regulation)

• Endometrial biopsy

Contraindication
• Endometrial biopsy in cases of suspected
pregnancy

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 Steps of the MVA Procedure
1. Prepare instruments
2. Prepare the woman
3. Perform cervical antiseptic preparation
4. Dilate cervix
5. Insert cannula
6. Suction uterine contents
7. Inspect tissue
8. Perform any concurrent procedures
9. Process instruments

44

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Video: MVA procedure

45
Signs that the uterus is empty

• Red or pink foam without tissue passing through

cannula
• Gritty sensation over surface of uterus
• Uterus contracting around cannula
• Increased uterine cramping

46
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 Complications of MVA
• Vagal reaction
• Incomplete evacuation
• Uterine/cervical injury
• Pelvic infection
• Acute hematometra

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