ABORTION

Learning outcomes and objectives

• Define abortion and its causes
• Classification of abortion using a flow chat or tree diagram.
• Types of spontaneous abortion
• Induced abortion and various procedures of its management.
• Abortion and the Law: past and present.
• Signs and symptoms of each type of abortion; and complications of
abortions.
• General management of abortion: clinical, psychological, social,
legal and spiritual.
ABORTION
• Termination of pregnancy, either spontaneously or intentionally

• Pregnancy termination prior to 12 weeks’ gestation

• Definition varies according to the Country laws for reporting

abortions, foetal deaths, and neonatal deaths
ABORTION
• Any bleeding in pregnancy is abnormal

• The term miscarriage & abortion are used interchangeably

Abortion has been legalized under certain circumstances
at various points in history, such as:

• A risk to the mother’s health -----------------------Therapeutic

• If the pregnancy was the result of a crime ---------Elective
• Risk to the child’s health --------------------------------Therapeutic
• Socio-economical reasons ------------------------------Elective
• Governmental Policy -------------------------------------Elective (often
forced)
Spontaneous abortion
• Abortion occurring without medical or
mechanical means to empty the uterus is
referred to as spontaneous.
• Fetus born before 12 weeks
• Another widely used term is miscarriage
Spontaneous abortion
• In the first 3 months of pregnancy
Death of the embryo or fetus nearly always precedes
spontaneous expulsion of the ovum

Finding the cause of early abortion involves ascertaining the

cause of fetal death
- In subsequent months
The fetus frequently does not die before expulsion
Other explanations for its expulsion should be sought
Induced Abortion
• The medical or surgical termination of pregnancy before the time of
fetal viability (24 weeks)
• Indication
• Continuation of pregnancy may threaten the life of the woman or seriously
impair her health
• Persistent heart disease after cardiac decompensation
• Advanced hypertensive vascular disease
• Invasive carcinoma of the cervix
Induced Abortion continues….

• Pregnancy resulted from incest because of same

gene pool with bad genes

• Continuation of pregnancy is likely to result in the

birth of child with severe physical deformities or
mental retardation
Spontaneous abortion

• Factors that can contribute to Spontaneous Abortion

Fetal Factors
Maternal Factors
Paternal Factors
Environmental Factors
Foetal Factors
• Genetic- chromosomal issues

• Foetal conditions

• Multiple pregnancy
SPONTANEOUS ABORTION
• Pathology of the fetus or mother may lead to:
• Maceration of the fetus
The skull bones collapse, the abdomen distends with
blood-stained fluid, and the internal organs degenerate

The skin softens and peels off in utero or gets slightest

tough
Spontaneous abortion
When amniotic fluid is absorbed, the foetus may become
dehydrated and compressed → fetal compressus

The fetus become so dry and compressed that it

resembles parchment - a fetus papyraceous
Maternal Factors
The risk increases with parity as well as with
maternal and paternal age
The frequency of abortion increases from 12
percent in women younger than 20 years to 26
percent in those older than 40 years
If a woman conceives within 3 months following a
term birth → incidence of abortion ↑
Maternal factors continue…
• Laparotomy/abdominal surgery
Surgery performed during early pregnancy
Peritonitis increases the likelihood of
abortion
• Physical trauma
Major abdominal trauma→ ↑ abortion
Maternal Factors continue…
• Incompetent cervix – Etiology/Causes
• Previous trauma to the cervix e.g. physical abuse,
violence
• Dilatation & curettage
• Cauterization
• Abnormal cervical development ( congenital
abnormalities)
Maternal Factors continue…
• Incompetent cervix:
• Painless dilatation of cervix in the 2nd or early in the 3rd
trimester
→ prolapse & ballooning of membranes into vagina
→ rupture of membrane & expulsion of immature fetus
• Unless effectively treated, tends to repeat in each
pregnancy. Cervical suturing becomes necessary
Maternal Factors continue…
Maternal Factors continue…..

 Uterine ADHESIONS
(Asherman syndrome)
Form when scar tissues
builds up in inner walls
causing them to bind
together
Maternal Factors continue…..
• Uterine ADHESIONS(Asherman syndrome)
Cause : destruction of large areas of
endometrium by curettage, leading to
→ insufficient endometrium to support
implantation
→ recurrent abortion, amenorrhea,
hypomenorrhea
Uterine defects – acquired uterine defects

• UTERINE GROWTHS:
usually not DIRECT cause
of abortion but,
• Placental implantation
over or in contact with
myoma fibroid
→ placental abruption,
abortion, ↑ preterm labor
→ location is more
important than size
FIBROIDS
Spontaneous abortion – Maternal factors
• Incompetent cervix – Treatment
• The operation is performed to surgically
• Reinforcement of weak cervix by some type of purse
string suture
(Cerclage:cervical stitch)

For at least a week before & after surgery till the baby is born →
sexual intercourse should be restricted
Strict bedrest
McDonalds

•Non-absorbable suture
•Commonly used nowadays
Shirodkar
• Performed at ±16- 18 weeks gest.
• Also a stitch on the cervix
Removal:
• At 37 weeks or earlier if labour occurs or features of
abortion occur
• If not done in time: uterine rupture or cervical tear
Paternal Factors
• Genetic abnormalities of the sperm

• Infections (viral/bacterial) e.g. STIs

Environmental Factors
Environmental toxins
 Pesticides, metals, air pollution
 Arsenic, lead, benzene, ethylene oxide →
abortifacient
 Radiation,
 short waves & ultrasound DO NOT
increase the risk of abortion
Environmental Factors continue….
 Drug use and environmental factor
Radiation
In sufficient doses → abortifacient

Contraceptives
When intrauterine devices fail to prevent pregnancy →
abortion↑
Threatened abortion
• Definition
Any bloody vaginal discharge or bleeding during 1st half of pregnancy
Bleeding is frequently slight, but may persist for days or weeks
• Frequency
Extremely common (one out of four or five pregnant women)
• Prognosis
Approximately ½ will abort
Risk of preterm delivery, low birthweight, prenatal death↑
Threatened abortion continues…
• Symptoms:
• Usually bleeding begins first
• Cramping abdominal pain follows a few hours to several days later
• Presence of bleeding & pain
→ Poor prognosis for pregnancy continuation
• Treatment:
• Strict Bed rest
• No sexual intercourse
Inevitable Abortion
Usually first trimester
- Cervix is dilated, but products not expelled
- bleeding and lower abdominal cramping

• Treatment:
- Provide support for miscarriage completion
Missed Abortion
• Also known “silent miscarriage”
• Foetus dies in utero, products of conception remain in
uterus
• It is not spontaneous
• Does not have SYMPTOMS e.g. bleeding & cramping
• Not easily detected
Missed Abortion continues…
• Treatment:
- When no symptoms of pregnancy present, e.g. nausea, baby
movements e.c.t.
NB: mostly detected during ANC visits
- Medication to expel the contents
- Dilation & curettage (D&C)
Recurrent Abortion
• Also known as Habitual abortion
- Three or more consecutive pregnancy loss
• Treatment:
- Depends on cause
- Corrective surgery- uterine abnormalities
- Cause not known, difficult to treat
- Emotional support, couple
Complete abortion
- Expulsion of all products of conception
- Vaginal bleeding for several days
- Cramping like labour pains common
• Treatment:
- If it occurs at home, consult medical practitioner to
ensure completion
Incomplete Abortion
- Expulsion of SOME products of conception
- Vaginal bleeding and lower abdominal cramping as
the uterus tries to empty itself
• Treatment:
- D&C to remove any remains
- Theatre procedure
Induced abortion
• The medical or surgical termination of pregnancy before the
time of fetal viability

• Therapeutic abortion:

-Termination of pregnancy before fetal viability for the

purpose of saving the life of the mother
Induced abortion
• Indication
-Continuation of pregnancy may threaten the life of a woman or seriously
impair her health
• Persistent heart disease after cardiac decompensation
• Advanced hypertensive vascular disease
• Invasive carcinoma of the cervix

-Pregnancy resulted from incest because of same gene pool with bad genes

-Continuation of pregnancy is likely to result in the birth of a child with severe

physical deformities or mental retardation
Induced abortion
• Elective (voluntary) abortion
-Interruption of pregnancy before viability at the request of the women, but not
for reasons of impaired maternal health or
fetal disease
• Counseling before elective abortion
-Continued pregnancy with its risks & parental responsibilities
-Continued pregnancy with its risks & its responsibilities of arranged adoption
-The choice of abortion with its risks and responsibilities
Medical Abortion
Procedure that uses medication to end pregnancy
Mifepristone (RU 486) given
• Competes with progesterone
• 2 – 3 days-
Misoprostol is given
• Also has prostaglandins
• Expels the baby
• Done mostly at hospital
Medical Abortion cont….

• acceptable alternative to surgical abortion

in women with pregnancies of less than 49
days’ gestation
More info on medical abortion
Oral agent used alone in combination with oral PG to effect abortions in early gestation
High receptor affinity for progesterone binding site
 → Block progesterone action
Abortion rate
Single 600mg dose prior 6 weeks → 85%
Addition of oral, vaginal or injected PG → over 95%
If given within 72 hours
Also highly effective as emergency postcoital contraception
Progressively less effective after 72 hours
Side effects
Nausea, vomiting, & gastrointestinal cramping
Major risk → hemorrhage is a risk if abortion is incomplete
Surgical techniques for abortion
• Dilatation and curettage

-Performed first by dilating the cervix & evacuating the product of conception
• Mechanically scraping out the contents (sharp curettage)
• Vacuum aspiration (suction curettage)
• Both

-Before 14 weeks, D&C or vacuum aspiration should be performed

-After 16 weeks, dilatation & evacuation (D&E) is performed

• Wide cervical dilatation
• Mechanical destruction & evacuation of fetal parts
Surgical techniques for abortion
• Complications : uterine perforation
• 2 important determinants
• Skill of the physician
• Position of the uterus (retroverted)

• Suction & sharp curettage

→ Considerable intra-abdominal damage risk↑
→ Laparotomy to examine abdominal content (safest action)

• Other complications – cervical incompetence or uterine synechiae

Relationship between abortion and health
• Abortion may cause mental health problems

• Abortion and mental health problems are due to some common third
factor (confounder) e.g. poverty, childhood deprivation, poor support

• ABORTION may lead to infertility and in some cases, pelvic region

health problems
SUCTION ASPIRATION
Slightly more effective (about
99%)
Shorter time to completion
Shorter bleeding duration
Can be performed later in
gestation
Post Abortion Care
1. Emergency and continuation treatment
2. Psychological counseling
3. Social and cultural support
4. Contraceptive counseling, STI and HIV evaluation and treatment.
5. Community involvement