ABORTION AND ITS

COMPLICATIONS
PRESENTED BY
DR T.K NYENGIDIKI
• INTRODUCTION
• BURDEN OF THE PROBLEM
• PREDISPOSING FACTORS TO
COMPLICATIONS
• COMPLICATIONS
• PREVENTION OF COMPLICATIONS
 INTRODUCTION
• Ancient as mankind-prevention of unwanted birth
• 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
pregnancies- spontaneous 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.
 PREDISPOSING FACTORS TO
UNSAFE ABORTION
• Lack of adequate legislature and policies to regulate the procedure.
• Financial constraints on the part of the affected persons:
-to raise children
-to seek adequate contraception
-Acquire appropriate education
-Seek procedure under safe conditions
-medical care for treatment of complications.
• Low illiteracy levels
• Unstable family set up
• Societal outlook and taboos
• Single parenthood
• Student pregnancies
• Religious condemnation of pregnancies etc
• Lack of information about complication of procedure, preventive
measures prevalence of unsafe abortions.
 Complications
• EARLY • LATE
-Incomplete abortion • -Chronic pelvic inflammatory
disease
-septic abortion
• -pelvic adhesions
-septic shock
• -chronic tubo-ovarian masses
-Injury
• -chronic pelvic pain
-vagina, cervix, uterus
• -tubal occlusion
-perforation of large /small
bowels • Ectopic Gestation
-Acute renal failure • Infertility
-Dissseminated intravascular • Asherman’s syndrome
coagulation -infertility
-Haemorrhage -oligomenorrhoea /amenorrhoea
-pelvic abscesses -intrauterine adhensions
-septic pelvic thrombophlebitis
-Septic arthritis • Psychological factors
-Tetanus -grief
Adult respiratory distress syndrome -regrets
-dejection
• INCOMPLETE ABORTION
• history
-Attempted criminal
termination
-Passage of fetal parts
-Abdominal pains
• Exam
• Pale,tachycardia,hypotension
–severe blood loss.
• Uterine size < gestation
• Abdominal tenderness
• Cervical os open with products
• Investigation
• Full blood count- Hb
• Grouping and cross matching
of compatible blood
• Ultrasound scan
• TREATMENT
• Resuscitation: Normal saline,
Ringers lactate,blood transfusion
• Use of oxytocics
• -intravenous bolus of
ergometrime-0.5mg stat
• -intravenous oxytocins 40 units in
one litre of normal saline at a rate
of 30-60 drops per minute.
• Arrangement for evacuation of
retained products
-Surgical -manual vacuum
aspiration
(98% )
-Medically- Oral misoprostol
400mg alone .
-Intramuscular sulprostone
0.5mgstat
(95% )
. Adminstration of Anti D
immunoglobulin-250units.
.Counseling and psychological
support
Prophylactic antibiotics
 Septic abortion
•
• Investigations
Presence of intrauterine infection after
an abortion • HVS, intracervical, intrauterine
-organisms: microscopy
pneumococci, streptococci, staph, • FBC+ESR
E.coli,Stspp,
klebsiella, proteus pseudomonas spp. • Blood grouping and typing
Predisposing factors • Midstream urine
Criminal abortions • Electrolyte, urea and creatinine
Retained products • Coagulation studies
Clinical features
.Hx of criminal termination-may not be • Erect abdominal X ray
volunteered • Ultrasound sound
.Fever, pallor, jaundiced, furred tongue
tachycardia with sometimes evidence of
hypotension-toxic shock. • Treatment
Evidence of peritonitis: • Resuscitation
- Abdominal • Blood transfusion
-tenderness/rebound tenderness distension. • Strict input and output chart
-Reduction of bowel sounds
-Malodorous blood stained discharge from • Antibiotics- triple regiment
cervix • Tetanus prophylaxis- T.Toxiod-
-Cervix may be opened or closed 0.5mg Stat, H.I.T Globulin 250-
-Positive C.E.T 500mgStat.
 SEPTIC SHOCK
• _Caused by release of • Treatment
toxins by organisms such • Adequate infusion of crystalloids
as E.Coli,Klebsiella colloids, blood transfusion
,Proteus ,Bacteriods Etc • Refractory shock
• -affects small vessels- -+vasopressors –Dopamine
cvs collapse. (renal dose)->6g/kg/hr
.HA-1A- Human monoclonal IgM
• Clinical features antibodies (centroxin)-100mg in
• Warm extremities, 3.5g of Albumin
Hypotension-in the face .Oxygen by face mask
of adequate fluid .Monitoring of vital signs.
replacement. Other .Severe cases
evidence of sepsis. -Endotracheal intubation/O2
-Respirator care
-ECG monitoring
-Pulse oximeter CVP monitoring
 INJURIES
• Genital tract laceration- • Perforation
vaginal cervix ,uterine • Stop the procedure, observe
perforation closely,-cardiovascular
compromise.
• Clinical features • Not present- antibiotics
• Bleeding, abdominal pains • Present – laparotomy
,marked suprapubic • Laparotomy –Extent of injury
tenderness, signs of and effect repairs
intraperitoneal -hysterectomy
hemorrhage. -extensive damage
• Treatment Options -clostridium infection
• Prompt resuscitation, -gangrene/necrosis
-drainage and peritoneal
• Repair of vaginal/cervical lavage did not produce an
lacerations improvement in condition
 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
 Acute renal failure
• Urinary output < 30mls • Treatment
per hour despite • Initial
adequate hydration and -adequate hydration
blood transfusion
• Deranged electrolyte -Fluid challenge with 200-
urea and creatinine 250 mls of mannitol or iv
frusemide 100-200mg
• Diagnosis made
If established
• -refer to renal unit
-Restrict fluid, institute renal
failure regiment- high
CHO, low protein and low
potassium
Dialysis-Hemodialysis or
Peritoneal
 Disseminated intravascular
coagulation
• -inappropriate activation of the nvestigations
I

coagulation and fibrinolytic system -Low platelets <100,000/ml

• Causes -Increased prothrombin time
-low fibrinogen <150mg/dl
-saline induced abortion -clotting time elevated
-septic abortion -bleeding time elevated
-septicaemia -fibrin degradation products elevated
-massive blood transfusion Treatment
Mx -Correction of underlying dx
Release of tissue thromboplastins and -supportive treament
bacteria endotoxins -correction of shock,acidiosis
Clinical features -cardiopulmonary support
Generalized bleeding, localized -fresh whole blood transfusion –
massive haemorrhage
purpura ,petechia and -platelet transfusion-platelet count <
thromboembolic phenomenon, fever, 50,000/ml
hypotension ,proteinuria frank -subcutanous low dose heparin-
intravascular clotting process
gangrene
-contraindicated in fulminant D .I.C
and liver failure.
Prognosis
Good when treatment is started early
 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.
 TERTIARY PREVENTION CONT

• Provision of equipments for manual

vacuum aspiration and supplies of
contraceptives.
• Pre-service training of staff on all aspects
of abortion, post abortion care
contraceptive delivery and quality care
framework.