ABORTION

MRS B.M.N. KAPETA

BSC/RM/RN
(2014)

GENERAL OBJECTIVE
To equip students with skill and
knowledge to identify types of
abortions and enable them to provide
comprehensive services that will
meet the clients needs.

SPECIFIC OBJECTIVES

Define abortion
State the different causes of abortion
State the classification of abortions
Mention the signs and symptoms of
specific types of abortion
Discuss immediate management of
specific types of abortion

INTRODUCTION
Globally, of all maternal deaths
approximately 15% are related to
unsafe abortion. Uterine abortion is
the commonest cause of vaginal
bleeding in early pregnancy. It
accounts for 95% of cases of
bleeding in early pregnancy. In
Zambia 30% of maternal deaths are
as a result of abortions..

Cont
Pregnancy is not a disease but still,
its a major killer among young
women in the world today. However
bleeding in early pregnancy can be
caused by other pregnancy
complications such as ectopic
pregnancy, and molar pregnancy
being the most serious.

Cont
Abortion is important not only
because of the loss of the wanted
pregnancy, but because its an
important cause of maternal death
from the haemorrhage and sepsis
which may follow a mismanaged
abortion

Introd cont,
Its also vital to note that in abortal
services, certain human rights should
be respected, such as right to life,
right to privacy, right to information
and education, right to decide
whether or when to have children.

DEFINITIONS

Abortion is an expulsion of products of

conception before the 28th week of
gestation and before viability of the
fetus (Hossan 1982)

Abortion is loss of pregnancy before

the 28th week or loss of fetus weighing
less than 500g (WHO)

TYPES OF ABORTIONS
Spontaneous abortion also known as
miscarriage is the unintentional expulsion
of an embryo or fetus before the 24th
week of gestation.
or an involuntary loss of the products of
conception prior to 24 weeks gestation
Induced abortions- Its an intentional or
voluntary disruption of the products of
conception before the 24th week of
gestation

Definitions cont,

Therapeutic Abortion: A medically

performed abortion to save the life of
the pregnant woman; prevent harm
to the woman's physical or mental
health; terminate a pregnancy where
indications are that the child will
have a significantly increased chance
of premature morbidity or mortality
or be otherwise disabled;

Cont
or to selectively reduce the number
of fetuses to lessen health risks
associated with multiple pregnancy.
Elective (Voluntary) Abortion: Is
performed at the request of the
woman for non-medical reasons.

CAUSES OF ABORTION

In many cases, no definite cause can be

found, however the following are
regarded as causes
a). FOETAL CAUSES
Mal-development of the conceptus- due
to chromosomal abnormalities which
accounts for 50% of the cases.
Genetic and Structural abnormalities

Causes cont
b). MATERNAL CAUSES
These include the following maternal
influences:
Maternal infections this is brought
about by the effects of fever on the fetus,
from acute illnesses like influenza or
rubella, the toxins are able to cross over
to the fetus, toxoplasmosis,
cytomegalovirus, syphilis, Chlamydia, etc.

Cont
Uterine abnormalities This
includes retroversion of the uterus,
bicornuate uterus, unicornuate uterus
and fibroids, Infantile uterus
Medical disorders conditions such
as anaemia lead to reduced fetal
perfusion as in renal disease,
diabetes, thyroid disease, and
hypertensive and renal disorders.

Cont
Cervical incompetence due to
Congenital weakness - owing to the weight of
the growing fetus, the weakened cervix starts
to dilate and hence not maintain the pregnancy.
Trauma - resulting from previous D&C or child
birth
Maternal Age and Gravidity data reveals
an increased risk with advancing maternal age
(over 30 yrs) and increasing gravidity (Oats &
Abraham, 2005).

Causes of abortions cont

Endocrine abnormalities Poor
development of the corpus luteum,
inadequate secretory endothelium and
low serum progesterone levels.
Psychological factor
Such as severe emotional stress/ anxiety
affects
the function of the hypothalamus
leading to the release of stress hormones
which cause vaso-constriction hence
reducing blood supply to the fetus

Causes cont
Trauma
Direct trauma to the uterus
Criminal interference
Drugs:
Large doses of all drugs
Cytotoxic drugs
Anaesthetic drugs

Causes cont
Environmental/ social factors
excessive consumption of alcohol leads
to malnutrition;
coffee due to caffeine causes vaso
constriction of blood vessels;
smoking ( nicotine causes vasoconstriction of blood vessels) women
who smoke 10 cigarettes per day
double their risk

Causes cont
including passive exposure to cigarette
smoke, have been found to increase the
risk of abortions.
Exposure to organic solvents such as lead
and radiation increases the likelihood of
fetal malformation and miscarriage
c). PATERNAL CAUSES
Poor sperm quality may be a factor which
may lead to fetal malformation.

CLINICAL TYPES OF ABORTION

SPONTANEOUS ABORTION
The stages of spontaneous abortion
may include:
Threatened Abortion (occurs in the
early weeks of pregnancy; pregnancy
may continue);
Inevitable Abortion (this pregnancy
will not continue and will proceed to
incomplete/complete abortion);

CLINICAL TYPES.. cont

Incomplete Abortion (products of
conception are partially expelled);
usually happens in the 2nd trimester
Complete Abortion (products of
conception are completely expelled).

Clinical types cont,

INDUCED ABORTION
Septic
Therapeutic
Complete
Incomplete

INVESTIGATIONS

History
Date of last menstrual period (LMP),
duration and amount of bleeding
severity of cramping
type of contraceptive used before
such as implants and injectables
Passage of products of conception
unexplained fevers and chills.

Investigations cont
Laboratory tests
Gravindex test confirms pregnancy
by presence of HCG and decreased
levels suggest abortion
Blood for culture and sensitivity will
confirm the septic abortion, the
causative organism and its
sensitivity.

Investigations cont

Ultra sound examination

A confirmatory test that will reveal:
Gestational sac
Presence or absence of fetal heart
sounds or an empty amniotic sac.

SPONTANEOUS ABORTIONS

THREATENED ABORTION
In this type of abortion, there is slight
painless vaginal bleeding during the
first three months of pregnancy. It
may be associated with slight lower
abdominal pain or backache but
there is no cervical dilatation.

Signs and symptoms

History of amenorrhea
Signs of pregnancy present
Height of fundus corresponds with dates
Uterus soft
With or without backache and lower
abdominal pains
Presence of scanty vaginal bleeding
Cervical OS closed

Management of threatened abortion

Obtain history and do physical

examination and vital sign observations
.
Bed rest is the most important form of
treatment. The patient should remain in
bed for 5-7days or for as long as blood
is bright red. Bed rest increases blood
flow to the placenta and reduces pain.
Abstinence from sexual activities

Management of threatened
abortion cont,
If uterine contractions become
stronger, analgesics such as
pethidine100mg intramuscularly or
morphine 15mg may be needed.
Pads should be saved in order to help
assess the amount of blood loss.
Report any increase in bleeding or
pain to the doctor for further
management.

AN INEVITABLE ABORTION
A condition in which the cervix has
already dilated, but the fetus is yet to be
expelled, this usually progresses to a
complete abortion or incomplete abortion.
Signs and symptoms
History of amenorrhea
Signs and symptoms of pregnancy present
Height of fundus may not correspond with
the gestational age

Signs and symptoms

cont,
Cramping Lower abdominal pains
and backache
Fairly heavy Vaginal bleeding
Cervical os is open
Products of conception maybe seen
at the vaginal introitus
May progress to either complete or
incomplete abortion

COMPLETE ABORTION

This is when all the products of conception,

which is the embryo and the placenta with
intact membranes, are expelled from the
uterus.
Signs and symptoms
History of amenorrhea
Signs and Symptoms of pregnancy present
Some backache and lower abdominal pains

Complete abortion cont

Uterus firm and well contracted
History of passage of the products of
conception
Diminishing or Minimal bleeding per
vagina
Cervical os closed

IMMEDIATE MANAGEMENT OF
COMPLETE ABORTION
Rest in bed, if possible with sedation
Evacuate uterus as soon as possible
to ensure completeness.
Check Hb after 24hours in case of
severe anemia due to severe
bleeding.
Curettage only needed if bleeding
persists

AN INCOMPLETE ABORTION

This is one in which part of the products of

conception, usually the fetus is delivered while
the placenta and membranes are retained. The
cervix is usually open. Incomplete abortion
when unattended to causes fatal complications.
Signs and symptoms
History of amenorrhea
Severe and Cramping lower abdominal pains
and backache
Abdomen soft, height of fundus may correspond

Incomplete abortion cont,

Abdomen soft
Heavy and profuse vaginal bleeding
Passage of some products of
conception, usually the fetus and the
placenta and membranes are
retained
Signs of shock

Incomplete abortion
cont
Immediate management of incomplete
abortion
Evacuate uterus under anesthesia or strong
analgesia
Replace blood if necessary or if the
hemoglobin level is below 5 grams.
Antibiotics only if febrile
Set up oxytocin drip to aid in expelling
retained products of conception by uterine
contraction.

Management cont
If patient is in shock start a plasma expander for
example dextran 50%, heamacil, drip after
taking blood for grouping and cross-matching.
Do a sterile vaginal examination and remove
any placental tissue distending the cervix with a
finger or sponge forceps
Give ergometrine 0.5mg intramuscularly. Once
these steps have been taken the condition
usually improves and the patient can safely be
transferred to hospital.

Incomplete abortion
cont,
If bleeding is light to moderate and
pregnancy is less than 16 weeks, use
fingers or ring (or sponge) forceps to remove
products of conception protruding through the
cervix.
If bleeding is heavy and pregnancy is less
than 16 weeks, evacuate the uterus:
Manual vacuum aspiration is the preferred met
hod of evacuation
. Evacuation by sharp curettage
should only be done if manual vacuum aspiration
is not available
;

Cont
If evacuation is not immediately
possible, give ergometrine 0.2 mg
IM (repeated after 15 minutes if
necessary) OR misoprostol 400 mcg
orally (repeated once after 4 hours if
necessary).

Cont
If pregnancy is greater than 16 weeks:
Infuse oxytocin 40 units in 1 L IV fluids (normal
saline or Ringers lactate) at 40 drops per minute
until expulsion of products of conception occurs;
If necessary, give misoprostol 200 mcg vaginally
every 4 hours until expulsion, but do not
administer more than 800 mcg;
Evacuate any remaining products of conception f
rom the uterus
.
Ensure follow-up of the woman after treatment

MISSED/DELAYED/SILENT ABORTION

This occurs when the fetus dies and is

retained in utero, together with the
placenta and membranes.
Signs and symptoms
History of amenorrhea
Signs of pregnancy regress
Height of fundus less than expected
Some spotting per vagina or brownish
vaginal discharge

Missed abortion cont

Cervical os closed
There is no pain.
Fetal heart cannot be heard by either
fetoscope or Doppler
Ultra sound may confirm the
abscence of fetal heart beat
Pregnancy test usually is negative

Missed abortion cont

Missed abortion is usually not tempered with
until after one month because it eventually
spontaneously initiates its expulsion. The
main complication of missed abortion is
disseminated intravascular coagulation (DIC)
which is profuse bleeding due to
hypofibrinogenemia . There is evidence of
poor response to oxytocin/pitocin. Refer cases
of missed abortion to hospital for surgical
evacuation to prevent any further
complications.

Cont
Management
Confirm the diagnosis
Spontaneous expulsion may occur on its own
later but the waiting period may be distressing to
the mother knowing she is carrying a dead fetus.
If the pregnancy is below12 weeks-16 weeks,
evacuation of retained products of conception
(ERPC) is done
If above 12/16 weeks induction with
prostaglandin E2 and oxytocin.(prostaglandin
brings about contractions of uterine muscles)

BLOOD MOLE AND CARNEOUS MOLE

Blood mole may arise in case of a missed

abortion where the zygote is surrounded
by a layer of blood (blood mole). The
mole usually forms after 2 weeks and is
retained for months. All the fluid is then
absorbed from the bloody mole leaving a
fleshy firm hard mass known as the
carneous mole. On examination, the mole
will resemble the placenta. A tiny embryo
may be seen at the centre of the mass.

SEPTIC ABORTION
Infection can easily set in or can complicate
any type of abortion. Therefore if infection
is disseminated into the systemic
circulation it is called septic abortion. The
commonest type of abortion that leads to
sepsis is illegal or criminal abortion.
Signs and symptoms
History of amenorrhea
History of abortion usually unsafe abortion

Septic cont

General discomfort
Pyrexia usually >38C,Chills and sweating
Headaches
Tachycardia
Uterus bulky and very tender on palpation
Foul smelling vaginal discharge
Cervical OS open
Chills and fever signifies serious infection
Generalized abdominal tenderness with rebound
tenderness, rigidity or distension

Septic abortion cont

Immediate management of septic
abortion
Treatment of these patients with septic
abortion is an emergency as delay may
result in severe complications or death.
Patients should be managed in the
hospital if possible
Resuscitate with intravenous fluids in
order to replace lost fluids.

Septic abortion cont

Give parenteral broad spectrum
antibiotics to combat infection.
Take a cervical swab for culture and
sensitivity before starting antibiotic
treatment
Blood transfusion can be given in
cases of low hemoglobin (5g/dl)

Complications of septic
abortion

Septicaemia
Bacteremia
Renal failure
Disseminated Intravascular Coagulation
(DIC)- inappropriate coagulation within
the blood vessels leading to the
consumption of clotting factors.
Secondary infertility
Sheehans syndrome (Pituitary Necrosis)

HABITUAL ABORTION

Also called recurrent abortion or recurrent

pregnancy loss (RPL) this is when the
patient has experienced 3 or more
consecutive spontaneous abortions, usually
after 14weeks of gestation. There is usually
no obvious cause but the commonest cause
is cervical incompetence. However some of
the known causes are chronic illness, such
as diabetes mellitus, and abnormalities such
as a septate uterus.

Cont
Causes
Often the cause is unknown
Incompetence of the internal os of
the cervix resulting from previous
trauma
Infections of low grade fever
Local lesions such as cervical erosion
Diseases like diabetes mellitus,
nephritis

Cont
Signs and symptoms
The abortion occurs late in the
second trimester usually between
the 22-24th week
There is no previous warning such as
vaginal bleeding
The membranes may rapture
suddenly followed by expulsion of the
conceptus
The abortus looks fresh

Cont
Management
Investigations to R/O systemic diseases
like diabetes, syphilis, cervical
erosion(RPR, FBC, blood sugar, Ultra
sound scan, cervical smear, full history)
Advise the mother to improve general
health by taking foods rich in proteins,
vitamins, minerals and to start a new
pregnancy as soon as possible

Cont
The woman should report to the
hospital as soon as they are pregnant
Treat her as a case of threatened
abortion
( bed rest)
Admit client if she cant rest at home
It must be emphasised/stressed to
the couple that coitus should not
take place for the rest of the
pregnancy

Cont
If the cervix is incompetent a
shirodkar suture of any non
absorbable suture material is tied
around the cervix at the level of the
internal os at about 14th-16th week
This operation should be recorded
clearly and boldly in the clients
antenatal records

Cont
The suture must be removed at about the
38th week or as soon as the client goes
into labour otherwise there are dangers of
uterine rapture if not removed in time.
Offer psychological care to the couple and
counselling them as treatment may not
always be effective
Mild sedatives may be required to
promote rest

Cont
INDUCED ABORTION
This is an intentional emptying of the
uterus. It can either be therapeutic or
criminal
Therapeutic abortion
This is evacuation of the uterus done
by a qualified medical practitioner. It
is provided for under the legal
framework; The Abortion Act of 1972.

Cont
Subject to the provisions of this
section, a person shall not be guilty
of an offence under the law relating
to abortion when a pregnancy is
terminated by a registered medical
practitioner if he and two other
registered medical practitioners,

Cont
one of whom has specialised in the
branch of medicine in which the
patient is specifically required to be
examined before a conclusion could
be reached that the abortion should
be recommended, are of the opinion,
formed in good faith

Cont
The Act states that pregnancy is
terminated if the pregnancy:
Involves risk to the life of the pregnant
woman e.g. a woman who has a condition
that is complicated by pregnancy
Involves risk of injury to the physical or
mental health of the woman
Involves risk to the existing children of the
family, greater than if the pregnancy were
terminated

Cont
Carries substantial risk that if the
child were to be born, it would suffer
from such physical and mental
abnormalities as to be seriously
handicapped e.g. German
measles/rubella
The Act further state that it is done if
two registered medical practitioners
are of the opinion that the pregnancy
should not continue. The spouse

Cont
A therapeutic abortion should be done
in the hospital where:i. Haemorrhage can be controlled,
Ii. Resuscitative measures are available and
Iii. Aseptic measures are always taken.
Staffs are however allowed to refuse to
advocate for or take part in abortions on
moral grounds. The moral issue is profound
and each one either the Dr or the nurse
should act according to their conscience

METHODS USED FOR TERMINATION OF PREGNANCY

1). Prostaglandin preparation

Induction is done after 12 weeks.
Prostaglandin E2 and E12.
Prostaglandin in misoprostol (cytotec)
is commonly used where it is inserted
in the cervix to induce labour.
Rapture of membranes should not be
done to reduce infection.

Cont
2). Vacuum aspiration
Vacuum aspiration is used for
pregnancies between seven and 12
weeks. A tube is inserted into your
womb through the cervix and suction
is applied to remove the womb
contents. This procedure takes 10 to
15 minutes and recovery time is one
to two hours.

Cont
3). Dilatation and Curettage (D&C)
D&C is used for pregnancies between 12
and 19 weeks. A speculum is inserted into
the vagina to view the cervix and a
slender rod (called laminaria) is used to
gently open the cervix. The pregnancy
may be removed using forceps and a
curved instrument (a curette) is used to
scrape the lining of the womb. Suction is
applied to remove the tissue.

Cont
This procedure takes about 30
minutes and is usually done under
general anaesthesia.
The removed tissue is examined to
make sure the termination is
complete and disposed of sensitively.

UNSAFE ABORTION/CRIMINAL

This is an abortion that is performed

in controversy or violation of the
Abortion Act of 1972 by unauthorized
persons and is punishable by law. It
may be done by the woman herself
or any other person.

UNSAFE .cont
Methods used
Drugs intoxication, Herbs, dettol,
chloroquine overdose
Insertion of sharp objects,
instruments, catheter, herbal sticks.
Successful or not the action is illegal

Risks of criminal abortion

Infection
Uterine perforation
Cervical laceration
Air embolus
Haemorrhage
Shock and death
infertility

CONCLUSION

We have discussed abortion and we said

that abortion is the expulsion of products
of conception before the 28th week of
gestation. An abortion can either be
induced or can start spontaneously.
Causes of abortion can either be maternal
or fetal, but there are cases where the
cause is not known. We also looked at
various clinical types of abortion such as
incomplete, complete and others.

Cont
All cases of abortion should be
considered incomplete until a
thorough investigation is done. They
should be treated as an emergency
because of the severe complications
that may arise if mismanaged such
as maternal death and severe
bacterial infection.

REFERENCES
Fraser D.M. et al (2003) Myles Textbook for
Midwives, 14th Edition, Elsevier Limited
Winkler J. et al, (1995) Post Abortion Care, A
reference manual for improving quality of care, Post
Abortion Care Consortium, United States of
America.
Sellers P.M, (2008) Sellers Midwifery Volume
11,Complications in Childbirth, Juta and Co, Ltd
Oats J and Abraham S (2005) Fundamentals of
Obstetrics and Gynaecology, 8th Edition,
Philadelphia; Elsevier Limited

THE END

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