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by Dr Dambo D. T.
• Most hazardous procedure –unsafe abortion • Unsafe Abortion- procedure of termination of pregnancy either by a person lacking in the necessary skilled or in an environment lacking the minimal medical standards or both (WHO 1992) • Clinically recognizable abortion -15-17% of pregnanciesspontaneous or induced. • Associated with complications • Induced abortion on its own is a result of failure of the complex often tricky balance act engaged in human to reconcile 2 aspects their life-Sexual intercourse & wish/reluctance to make babies.
Burden of the problem
• 26-53 million induced abortion annually • 40% in countries with restrictive laws • In Nigeria, .Abortion rates 25 per 1000 women , .610,000 abortion per year. . 40 % of maternal deaths • Netherlands – 5 per 1000 women.
• EARLY -Incomplete abortion -septic abortion -septic shock -Injury -vagina, cervix, uterus -perforation of large /small bowels -Acute renal failure -Dissseminated intravascular coagulation -Haemorrhage -pelvic abscesses -septic pelvic thrombophlebitis -Septic arthritis -Tetanus Adult respiratory distress syndrome • Death • • • • • • • • • LATE -Chronic pelvic inflammatory disease -pelvic adhesions -chronic tubo-ovarian masses -chronic pelvic pain -tubal occlusion Ectopic Gestation Infertility Asherman’s syndrome -infertility -oligomenorrhoea /amenorrhoea -intrauterine adhensions Psychological factors -grief -regrets -dejection •
Clinical presentation of septic abortion
• HISTORY: Hx. of an abortion may or may not be volunteered There is usually high grade fever Generalized, Suprapubic, lower abdominal or low back pain Offensive vaginal discharge EXAMINATION: General-Pale, febrile, jaundiced, furred tongue, offensive CVS-tachycardia and hypotension Abdomen- guarding, tenderness; generalized or suprapubic, may be distended with free peritoneal fluid, reduced bowel sounds
• V/E: There may or may not be bruises on vulva Vagina is usually hot Cervical Os may be open or closed Uterus and adnaexae are usually tender Pouch of Douglas may be full and tender Cervical motion tenderness is usually positive Gloved examining fingers are usually stained with offensive bloody vaginal discharge
• • • • • • Full blood count, Hb genotype Platelet count and clotting time Blood grouping and cross-matching, Rh. Status Urinalysis + urine M/C/S Serum E/U/Cr Abdomino-pelvic USS; Retained products of conception, abdomino-pelvic abscesses, peritonitis (dilated bowel loops), gas in the pelvis and fluid in the pouch of Douglas etc. • Plain erect abdominal X ray; gas, foreign body, uterine perforation
• Serious gynaecologic emergency that requires the involvement of senior members of the team as early as possible. • Adequate resuscitation is of vital importance Crystalloids or colloids Blood transfusion as necessary Strict input/output chart Antibiotics-Triple Regimen; Intraveinous Ampiclox 1-2gm 6hrly for 24- 48hrs Metronidazole 500mg 8hrly for 24-48hrs Gentamycin 80mg 8hrly for 5 days
• Other useful antibiotics; Cephalosporins-I.V. cefuroxime 750-1500mg 6-8 hourly for 24-72 hrs, Ofloxacin, ciprofloxacin 400mg daily • Evacuate the uterus after 24hrs of commencement of antibiotics. Switch over to oral antibiotics when appropriate as determined by culture and sensitivity results. ERPC should be done under general anaesthesia and extreme cautioned should be taken not to perforate the uterus if it has not been perforated already. • Analgesia; I.M Pentazocine 30mg 4-6 hrly with I.M promethazine 25mg 8-12hrly 24-48hrs • Tetanus prophylaxis; Tetanus toxoid 0.5mg stat, Human Immuno Tetanus Globulin 250-500 I.U. Stat
• • • Genital tract laceration-vaginal cervix ,uterine perforation Clinical features Bleeding, abdominal pains ,marked suprapubic tenderness, signs of intraperitoneal hemorrhage. Treatment Options Prompt resuscitation, Repair of vaginal/cervical lacerations • Perforation Observe closely,cardiovascular compromise. Antibiotics Present – laparotomy Laparotomy –Extent of injury and effect repairs -hysterectomy -extensive damage -clostridium infection -gangrene/necrosis -drainage and peritoneal lavage did not produce an improvement in condition
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Abscesses and intestinal injuries
• Massive pelvic and abdominal abscesses -pouch of douglas, paracolic gutters,general abdomen Clinical features -unrelenting fever, abdominal distensions, absent or reduced bowel sounds Investigations FBC,U/S scan, Erect plain abdominal X ray MGT • Co-management with the surgeons - antibiotics, laparotomy – midline incision - N/B No place for culdotomy - -bowel resection and anastomosis, colostomy -Drainage of abscesses -irrigation of abdomen with normal saline -Fascia closed with non absorbables -Massive Antibiotics
Prevention of unsafe abortion
• Preventable cause of maternal mortality and morbidity • This involves: - prevention of unwanted pregnancies - increasing access to safe abortion practices - effective management of abortion complications through post abortal care
LEVELS OF PREVENTION
Primary -provision of reproductive health information and choices -prevention of unplanned and unwanted pregnancies -provision of quality sexuality education to all ages. -Provision of sustainable contraceptive delivery service. - National policies on adolescent reproductive health should be formulated.
• Secondary -programmes /activities aimed at providing information and counseling to women experiencing unwanted pregnancy N/B: Not available b/c of restrictive laws Tertiary care -Provision of services for treatment of complications of unsafe abortion in 10,20 and 30 health facilities.
POST ABORTION CARE (PAC)
• Post abortion care is an approach for reducing morbidity and mortality from incomplete and unsafe abortion and its complications and for improving women's sexual and reproductive health and lives
Components of post abortion care
• Emergency treatment services for complications of spontaneous or unsafe abortion. • Post abortion family planning counseling and services • Links between emergency abortion treatment services and comprehensive reproductive health care • Community participation and education about PAC.