Abortion
Dr. Emmanuel Nii Okai Okine
Specialist Obstetrician-gynaecologist
Definition
• It is the termination of pregnancy before the
fetus is capable of extra-uterine life (viability),
or before the conceptus achieves a mass of
500g.
• The US uses 22 weeks, UK uses 24 weeks and
Ghana uses 28 weeks.
• The expelled embryo is called an abortus.
Incidence
• The incidence of spontaneous abortion
(miscarriage) has been estimated at 10-20% of
all pregnancies.
Types or classification
Spontaneous/ induced abortion Induced abortion
• Incomplete • Legal
• Complete • Illegal
• Inevitable
• Threatened
• Missed
• Blighted ovum
These could happen in a
sporadic or recurrent manner.
Aetiology- genetic
Chromosomal abnormalities account for 50% of
all 1st trimester abortions
• Trisomy 50% (21,22,15,16)
• Polyploidy 22% (3n, 4n)
• Monosomy 20% (45X)
• Structural chromosomal rearrangements 2-4%
(translocation, deletion)
• Others (mosaicism, double trisomy)
Two situations exist among the parents of
chromosomally abnormal abortuses:
• In most instances the couple is chromosomally
normal and the abortus’ abnormalities occur
in a random and sporadic fashion.
• In a small percentage of cases, one member of
the couple is a carrier of a balanced
translocation; offspring of these parents may
be repeatedly aborted.
Aetiology
Endocrine (10-15%)
• Luteal phase defects
• Diabetes mellitus
• Thyroid abnormalities
Anatomical (10-15%)
• Congenital malformation of the uterus
• Uterine fibroids
• Adenomyosis
• Asherman’s syndrome
• Cervical incompetence
Aetiology
Infections 5%
• Viral (Rubella, CMV)
• Bacterial (ureaplasma, chlamydia)
• Parasitic (toxoplasmosis, malaria)
Immunological 5-10%
• Autoimmune disease (ANA, APLA –aCL)
• Alloimmune disease (paternal HLA sharing with
mother)
Maternal medical illness (hypertension, cyanotic heart
disease, haemoglobinopathies)
Aetiology
• Antifetal antibodies (NK cells)
• Blood group incompatibilities
• Inherited thrombophilia
• Environmental factors (smoking, alcohol)
• Multiple pregnancy
• Trauma
• Unexplained
Threatened abortion
• Abortion is said to be “threatened” when a
pregnant woman experiences uterine
bleeding. Pain, if present at all is minimal. The
cervix will be found to be closed and
uneffaced. Uterine size is compatible with
gestational age. The process of abortion has
started but it hasn’t got to the stage at which
recovery is impossible.
• Differential diagnosis includes ectopic
pregnancy and molar pregnancy.
Investigations
• Pregnancy test
• Ultrasound to confirm intrauterine gestation,
fetal heart activity
• Blood for FBC, blood group with Rhesus factor
• Give anti-D Ig if rhesus negative.
Management
• Management is limited to explaining the
pathologic process and prognosis to the
patient.
• The patient is advised that there is no
increased risk of fetal congenital anomalies
when such pregnancy continues.
• Bed rest has not been found to be beneficial
as well injections with progestogens.
Prognosis
• 50% of pregnancies complicated by threatened
abortion have successful outcomes.
• 90% or more have a better chance when the
contents are normal and FH is present on
ultrasound.
• 30% will lead to inevitable or missed abortion.
• 60-70% will lead to pregnancy beyond 28
weeks with high risk for placenta previa, IUGR,
or preterm labour.
Inevitable abortion
• An abortion is inevitable when bleeding is
accompanied by pain and dilatation of the
internal os.
• There may be the loss of liquor.
• The process of abortion has reached a stage
that continuation of the pregnancy is not
possible.
• In pregnancies of 14 weeks or less, EOU is done
with MVA or sharp curettage to empty the
uterus.
Inevitable abortion
• In pregnancies of more than 14 weeks,
abortion is expedited by intravenous
administration of oxytocin drip (10IU in 500ml
NS), or misoprostol 400mcg 4hrly 3doses
depending on the state of the cervix and may
be followed by evacuation of the uterus if
placenta is retained.
• Blood transfusion is given if severe anaemia or
in haemorrhagic shock.
Complete abortion
• The abortion is termed complete when the products
of conception have been expelled en-masse. Lower
abdominal pain and bleeding PV subside or abolish
after the expulsion en-masse.
• The uterus is empty and the uterine size is normal or
less than the gestational age. The cervix is closed on
vaginal examination.
• Improve the general condition of patient with IV
fluids, blood if necessary.
• Pelvic USG to confirm that the uterus is empty.
Incomplete abortion
• Products of conception have expelled partially
from the uterus. Abdominal pain and bleeding
PV persists after expulsion of some fleshy
mass.
• The uterus is smaller than the gestation and
the cervix is dilated.
• If not treated, it could lead to severe
haemorrhage, sepsis, placental polyp,
choriocarcinoma.
Management
• Improve the general condition of the patient
with IV fluids
• Blood transfusion if severely anaemic or in
shock.
• EOU with the MVA kit or with currettage.
• Antibiotics may be needed, but not routinely
administered.
Missed abortion/ silent miscarriage/ early
fetal demise
• The term missed abortion is applied when the
conceptus dies (no fetal tones) but it is
retained in the uterine cavity.
• Diagnosis is confirmed by USG confirmation of
absent fetal heart beat. Pregnancy test may be
negative.
• Signs and symptoms of pregnancy would have
stopped or disappeared. There may be
abdominal pain with brownish vaginal
discharge. Uterine size is smaller, cervix is
closed and firm.
Missed abortion/silent miscarriage/ early
fetal demise
• If the conceptus is retained for more than 4
weeks there is a risk of DIC and infection.
• Investigations to be done include clotting
studies (bleeding time, clotting time,
prothrombin time), FBC (WBC, Hb, platelets),
pelvic USG will show absent fetal heart tones.
• The uterus should be evacuated once normal
clotting studies are obtained.
Blighted ovum/ anembryonic gestation
• There is an empty gestational sac at a time
that there should be a fetal pole or fetus.
When the mean sac diameter is 25 mm or
more in the absence of fetus suspect blighted
ovum.
• EOU is done to remove the products of
conception. Cervical ripening with misoprostol
may be done prior to dilatation and curettage.
Septic abortion
• Although any abortion may become infected septic
abortion usually follows criminal/illegal abortion due to lack
of asepsis, incomplete evacuation, genital tract injuries etc.
• The organisms are usually polymicrobial involving aerobic
and anaerobic occurring in mixed culture. Generally these
are Gram negative bacilli, most commonly E. coli and
Bacteroides fragilis and Gram positive cocci, particularly
enterococcus and beta hemolytic streptococcus.
• Aerobes- E. coli, enterococcus, streptococcus, staph,
Klebsiella
• Anaerobes- Bacteroides fragilis, Clostridium perfringes,
Clostridium tetani
Clinical features
• Fever of 38oC or more for more than 24hrs
• Abdominal pain
• Vaginal discharge
Signs
• Fever
• tarchycardia
• Abdominal tenderness
• Purulent vaginal discharge
• Uterus is boggy, tender, cervix dilated
Investigations
Blood
• FBC (wbc, hb, plt),
• grouping and crossmatching for haemotransfusion if severely
anaemic or shock.
• Blood cs
• RFT
• LFT
• Coagulation studies
Urine RE, cs
High vaginal swab and endocervical swab for Gram staining, and
cs
Investigations
USG
• Retained products of conception
• Pyometra
• Foreign body
• Fluid in the pouch of Douglas
Complications
• Haemorrhage
• Injury to intra-abdominal organs (bowel, bladder)
• Uterine perforation
• Septic endotoxic shock
• Acute renal failure
• Generalized peritonitis
• DIC
• Thrombophletis
• Tubal blockage (infertility, ectopic gestation)
• Chronic pelvic pain (dyspareunia)
• Emotional depression
Management
• Admission
• IV antibiotics
Gram positives- ampicillin
Gram negatives – ceftriaxone, gentamycin
Anaerobes- metronidazole
• Blood transfusion
• ATS 3000IU
• EOU (24hrs of IV antibiotics)
• Posterior colpotomy (to drain pelvic abscess)
• Laparotomy
• Hysterectomy
Indications for laparotomy
• Foreign body in the abdomen
• Pus in the abdomen not responding to
antibiotics
• Septic shock
• Injury to bowel, uterus
Habitual abortion
• 3 or more consecutive abortions
• Occurs in 1% of cases
Second trimester abortions
• Congenital- Mullerian duct defects, cervical
incompetence)
• Acquired (cervical incompetence, uterine
fibroids, Asherman’s syndrome)
Induced abortion
• It is elective termination of a pregnancy prior to
viability.
• The indications may be therapeutic or at the
patients request
• Methods of termination may be medical or
surgical.
• Medical termination uses mifepristone(RU 486)
an anti-progestin and misoprostol (cytotec).
Achieves up to 96% complete termination. It is
recommended for up to 9 weeks gestation.
Induced abortion
• Could also use mifepristone and misoprostol
• Cytotec alone can be used for termination but the
doses used vary according the gestational age
• The use of the MVA kit has made surgical termination
of pregnancy in the first trimester safe.
• The earliest intervention is “menstrual regulation”
which consist of aspiration of the endometrium
within 14 days of a missed period
• After six weeks of gestation, dilatation of the cervix
may be require for termination but with the MVA kit
this may not be necessary
Induced abortion
• The procedure for dilatation and suction for
termination of first trimester pregnancy is done
under paracervical block as an outpatient
procedure.
• Second trimester terminations are more difficult,
more dangerous and usually require admission to
hospital
• Methods used include intra-amniotic instillation
of prostaglandins, hypertonic saline or urea
solutions. Labour may be supplemented by the
use of oxytocin infusion once the membranes
have ruptured.
Induced abortion
• Hypertonic saline may lead to hypernatraemia
or diffuse coagulopathy in rare circumstances.
• Dilatation and evacuation may also be
performed between 12-20 weeks of gestation
provided it is performed by surgeons skilled in
the procedure. The cervix is usually softened
by prostaglandins.
• Cytotec has made second trimester
terminations easy and safe provided the
recommended doses are used
Induced abortion
• Complications of induced abortions include
hemorrhage, sepsis, septicemia and septic shock.
• Cervical laceration and uterine perforation
possibly accompanied by bowel injury and intra-
abdominal hemorrhage.
• Induction of abortion is safest when performed
at a period of gestation less than 9 weeks.
• Death to case rate increases by approximately
40-60% with each week of delay after the eighth
week.
Unsafe abortion
• An unsafe abortion is “a procedure for
terminating an unwanted pregnancy either by
persons lacking the necessary skills or in an
environment lacking the minimal medical
standards, or both.
• 210 million pregnancies occur each year
• 46 million (22%) end in induced abortion
• Nearly 20 million of these are unsafe
Unsafe abortion
complications of unsafe abortion depend on :
• Gestational age
• Provider
• Method used- sticks into the cervix, camphor,
coffee, paracetamol, ground beer bottle, ground
cockroaches and ants , gun powder, jumping unto
the abdomen
• Environment with respect to infection prevention
• Availability of services to cater for the
complication when they arise.
Post abortion care
Refers to care given to patients who suffer from
problems of unsafe abortion
Five elements of PAC:
• 1.Creating community awareness of the dangers
and complication of unsafe abortion
• 2. Community participation in the prevention of
unsafe abortion.
• 3. Treating the complication of the abortion-IVF,
blood, antibiotics, MVA/EOU, laparotomy etc.
Post abortion care
• 4. Post abortion contraception: patient can
ovulate within 2 weeks of first trimester
miscarriage and within 4 weeks of second
trimester miscarriage so the earlier she starts
a method the safer.
• 5. Linkage with other reproductive health
services eg. social welfare, DOVVSU etc
Thank you
