ABORTION

Introduction
• Abortion is one of the leading cause
of maternal mortality it accounts
• 13% world wide
• 4% in Africa
• 32%in Ethiopia (facility based)

Primary Causes of Maternal Death in
Africa
34%
17%
10% 9%
6%
4% 4% 4%
Source: Khan et al. , Lancet 2006

Causes of Maternal Death*
Haemorrhage
10%
Sepsis
12%
Hypertention
9%
Obstructed
labor
22%
Abortion
32%
Others
15%

Definition
 Abortion is expulsion of the products of
conception prior to viability of the fetus
(before 28 weeks of gestation) or less than
1000gm weight
 WHO gest. age<20 weeks or weight less
than 500 gm.

Cont..
• 50 % all fertilized eggs die and are lost
(aborted) spontaneously, usually before
the woman knows she is pregnant.
• Among those 15-20% the miscarriage rate
women who know they are pregnant
• Most miscarriages occur during the first 7
weeks of pregnancy.
• The rate of miscarriage drops after the
baby's heart beat is detected.

Cont..
• Septic abortion:-when any of the stage of
abortion complicated by pelvic infection
• Recurrent abortion:-three or more consecutive
spontaneous termination of pregnancies
• Unsafe abortion :-is characterized by lack or
inadequate of skill of provider, hazardous
technique and unsanitary facilities or both
• Therapeutic abortion :-termination of
pregnancy before the time of fetal viability for
the purpose of saving the life of the mother

Types of abortion
• Spontaneous
• Induced
Spontaneous abortion defined as the loss of a
fetus during pregnan cy 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…”

pathology In spontaneous abortion
• Hemorrhage into the decidua basalis often
occurs.
• Necrosis and inflammation appear in the area
of implantation.
• The pregnancy becomes partially or entirely
detached.
• Uterine contractions and dilatation of the
cervix result in expulsion of most or all of the
products of conception.

Etiology
• chromosome problems(common≈50%)
• Endocrine disorder like Luteal Phase defects
• Advanced age
• Drug and any poisons
• Exposure to environmental toxins
• Hormone problems
• Infection like TORCH

cont..
• Multiple pregnancies
• Physical problems with the mother's
reproductive organs
• Problem with the body's immune response
• systemic diseases in the mother e.g.
diabetes
• Smoking and alcohol
• Trauma

Clinical stages of abortion writing
Threatened abortion
oslight intermittent bleeding with or without
cramping
o The cervix remains closed and no cervical
effacement
oAt least 20–30% of pregnant women have
some first-trimester bleeding.
oIn most cases, this is thought to represent an
implantation bleed.
oMore than 50-80% go to term

Inevitable abortion
 The cervix has dilated, but the products of
conception have not been expelled
 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

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.

Sign and symptoms
• Cramps are usually present
• Profuse persistent bleeding
• HX of passing concepts tissue
• Some times visible or palpable concepts
tissue through the opening cervix
Complications
Anemia, hemorrhage and infection

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
Complications
Infection, DIC, AF embolism

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.

Blighted Ovum
• Blighted ovum or an embryonic pregnancy
represents a failed development of the
embryo so that only a gestational sac, with
or without a yolk sac, is present.
• An alternative hypothesis proposes that
the fetal pole has been resorbed prior to
ultrasound diagnosis

Differential diagnosis
• Idiopathic bleeding in a viable pregnancy
• Ectopic pregnancy
• Molar pregnancy
• Infection of the vagina or cervix
• Cervical abnormalities
–Malignancy, polyps, trauma
• Vaginal trauma

Diagnosis
Laboratory
-HCG levels
-Progesterone levels
Ultrasound
- Status of the pregnancy
- Intrauterine? Ectopic?
Vaginal Exam: dilated cervix ~> inevitable
abortion

Abortion ?or not?
Progesterone HCG Ultrasound Abortion?
>25 ng per mL
Increases
(48 hours)
Normal No
<5 ng per mL
Plateau or
decrease
Nonviable
pregnancy
Yes

Complications
• Severe or persistent hemorrhage life
threatening.
• Sepsis develops most frequently after
self-induced abortion.
• Intra abdominal injury
- Perforation of the uterine wall may
- injury to the bowel and bladder

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)

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

Laboratory investigations
• Blood type and RH factor
• Complete blood count
• HCG to confirm pregnancy
• WBC and differential to rule out
infection

General management writing ?
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.

Cont..
• Anti D for RH negative
• Surgical evacuation
-Patient is unstable:-Heavy bleeding
-Septic abortion
-Patient choice
• Medical therapy
 Missed spontaneous abortion
• Expectant management
• Completed spontaneous abortion
• Incomplete spontaneous abortion??

Treatment
For treated abortion
Bed rest and pelvic rest
Avoid coitus, douching and strenuous
exercise
• Prognosis is good when bleeding
and/or cramping resolve.

For inevitable abortion
• According to gestational age
<14 weeks MVA
>14weeks oxytocin infusion and
E/C with pethdine or sedative

For incomplete abortion
• Evacuation based on gestational age
• Uterotonic agents
• Blood and fluid replacement
• Antibiotic
• The prognosis for the mother is excellent
if the retained tissue is promptly and
completely evacuated.

For complete abortion
• observed for further bleeding.
• The products of conception should be
examined.
• prognosis for the mother is excellent

For missed abortion
Expectant management
-3-4 weeks follow up
-Clotting profile
>14weeks
-Prostaglandin or balloon catheter to dilate
cervix
-Pitocin
<14 weeks :-MVA or D/c

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

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

Etiology
Three generally accepted etiologies of
recurrent miscarriages are:-
• Chromosomal abnormalities
• uterine malformations
- bicornuate or septate uterus
- cervical incompetence
• Immunologic Factors
-Antiphospholipid antibodies

Others etiology
• sub mucous myomas
• Hormonal causes like hyper and
hypothyroidism
• Infection
• Maternal system disease e.g. diabetes
• Chronic malnutrition

Treatments
• Pre implantation diagnosis, or prenatal
testing on subsequent conceptions.
• Uterine operation: hysteroscopy resection
• Cervical cerclage
• myomectomy.
• Appropriate antibiotics

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 . . .”

Pathogenesis
• Instrument by illegal abortion or
ascending infection from the vaginal
cavity to normal sterile uterus

Sign and symptoms
• fever, shivering
• malodorous vaginal discharge
• pelvic and abdominal pain
• Rebound tenderness
• cervical motion tenderness.
• Peritonitis and sepsis

Investigations
• A complete blood count
• Hct ,blood group and cross match
• Urine culture and sensitivity
• endometrial cultures
• abdominal x-ray to rule out uterine
perforation should be obtained
• Ultrasound may be helpful in ruling out
retained products of conception.

Management
• Hospitalization and intravenous antibiotic therapy
• Broad spectrum antibiotic (ciprofloxacin+
gentamycin)
• Monitor v/s
• Blood transfusion if Hgb is low
• Remove focus of infection
• T.A.T to prevent tetanus
• Anti D for RH negative
• Post abortion care
• Hysterectomy for pelvic abscess and severe
perforation

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.

Why is PAC an important intervention?
• Saves women’s lives, increases use of FP, and
prevents repeat abortion
• Is acceptable where induced abortion is legally
restricted
• Links curative service (treatment for
complications) with preventive service (FP)
• Should be included in the existing range of
services and should not be a separate , vertical
service
• Can be offered successfully in low resource
settings

Magnitude of the problem of
unsafe abortion
• About 40-50 million women experience
abortions annually and 50% of these are unsafe
• 13% of maternal mortality–67,000 women–8
women die every hour
• 38 to 68% are less than 20 years old
• 10 to 50% need medical care
• More than 95% of deaths and injuries from
unsafe abortion occur in developing countries.
• ratio of 1 unsafe abortion for every 7 live births
.

Other factors that complicate the problem of
unsafe abortion:-
• Unmet need for contraception to delay, space
or limit pregnancies
• Unmet need for sexually transmitted infection
(STI)/HIV prevention and care

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.

cont..
3. Reproductive and other health services
• Preferably provide on - site, or via referrals to
other accessible facilities in provides’ networks.

Cont..
4. 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.

Cont..
5. Counseling
• Identify and respond to women's emotional
and physical healthy needs and other concerns