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Abortion power point.pptx

  2. Introduction • Abortion is one of the leading cause of maternal mortality it accounts • 13% world wide • 4% in Africa • 32%in Ethiopia (facility based)
  3. Primary Causes of Maternal Death in Africa 34% 17% 10% 9% 6% 4% 4% 4% Source: Khan et al. , Lancet 2006
  4. Causes of Maternal Death* Haemorrhage 10% Sepsis 12% Hypertention 9% Obstructed labor 22% Abortion 32% Others 15%
  5. 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.
  6. 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.
  7. 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
  8. 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…”
  9. 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.
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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.
  15. 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
  16. 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
  17. 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.
  18. 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
  19. 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
  20. Diagnosis Laboratory -HCG levels -Progesterone levels Ultrasound - Status of the pregnancy - Intrauterine? Ectopic? Vaginal Exam: dilated cervix ~> inevitable abortion
  21. 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
  22. 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
  23. 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)
  24. Prevention • Early obstetric care • Treatment maternal disorders like diabetes and hypertension • Protection of pregnant women from environmental hazards and exposure to infectious diseases.
  25. Laboratory investigations • Blood type and RH factor • Complete blood count • HCG to confirm pregnancy • WBC and differential to rule out infection
  26. 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.
  27. 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??
  28. Treatment For treated abortion Bed rest and pelvic rest Avoid coitus, douching and strenuous exercise • Prognosis is good when bleeding and/or cramping resolve.
  29. For inevitable abortion • According to gestational age <14 weeks MVA >14weeks oxytocin infusion and E/C with pethdine or sedative
  30. 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.
  31. For complete abortion • observed for further bleeding. • The products of conception should be examined. • prognosis for the mother is excellent
  32. 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
  33. Treatment of complication Managed accordingly • laparotomy are indicated to determine the extent of laceration or bowel injury • Broad spectrum antibiotics for sepsis
  34. 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
  35. Etiology Three generally accepted etiologies of recurrent miscarriages are:- • Chromosomal abnormalities • uterine malformations - bicornuate or septate uterus - cervical incompetence • Immunologic Factors -Antiphospholipid antibodies
  36. Others etiology • sub mucous myomas • Hormonal causes like hyper and hypothyroidism • Infection • Maternal system disease e.g. diabetes • Chronic malnutrition
  37. Treatments • Pre implantation diagnosis, or prenatal testing on subsequent conceptions. • Uterine operation: hysteroscopy resection • Cervical cerclage • myomectomy. • Appropriate antibiotics
  38. 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 . . .”
  39. Pathogenesis • Instrument by illegal abortion or ascending infection from the vaginal cavity to normal sterile uterus
  40. Sign and symptoms • fever, shivering • malodorous vaginal discharge • pelvic and abdominal pain • Rebound tenderness • cervical motion tenderness. • Peritonitis and sepsis
  41. 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.
  42. 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
  43. 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.
  44. 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
  45. 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 .
  46. 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
  47. 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.
  48. cont.. 3. Reproductive and other health services • Preferably provide on - site, or via referrals to other accessible facilities in provides’ networks.
  49. 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.
  50. Cont.. 5. Counseling • Identify and respond to women's emotional and physical healthy needs and other concerns