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ABORTION

• Definition: This is the expulsion of the products of


conception before the 28th week of pregnancy.
Incidence
• 15% of all pregnancies are said to result in an
abortion, most of them occurring in the first trimester
between 8 – 12wks of pregnancy
• Causes
• In most instances the causes remain unknown, but
may include the following;
• Fetal causes – Chromosomal abnormalities of the
conceptus, defective implantation,
• Maternal causes
• Maternal diseases like DM, Hypertension,
chronic heart failure, renal disease, severe
anemia and malnutrition. These conditions
interfere with transplacental respiration hence
precipitate abortion.
• Drugs, large doses of any drug are poisonous and
should be avoided.
• Infections like rubella, febrile conditions like malaria
• Maternal age- the risk increases with advancing age
• Local conditions- bicornuate uterus ,retroversion of
the uterus, fibroids, cervical incompetence
• Psychological factors – stress and anxiety where the
function of the hypothalamus and pituitary gland are
affected thus leading to alteration in the level of
pregnancy hormones affecting the uterine activity.
• Environmental factors – excessive consumption of
alcohol and coffee along with cigarette smoking
including passive exposure to cigarette smoke.
CLASSIFICATION of abortion
• Spontaneous abortion
• Induced abortion
Types of spontaneous abortion
• Threatened
• Inevitable
• Incomplete
• Complete
• Missed
• Septic abortion
• Recurrent/Habitual abortion
• Induced abortion
-Therapeutic - Illegal
Threatened Abortion

• Mother presents with history of amenorrhea and signs


of pregnancy may be present
• Uterine bleeding may be scanty with or without low
backache and cramp like pains.
• No rhythmic uterine contractions
• On speculum examination the cervical os is closed
• U/S scan shows a normal amniotic sac and fetus
whose heart is beating.
• 98% of threatened abortion the pregnancy continues.
Treatment for threatened abortion

– Medical treatment usually not necessary


– Avoid strenuous activities and sexual intercourse -
Bed rest
– treat precipitating factors
– Continue with nursing care
– repeat ultra sound scan
Discharge if she improves and encourage to return to
the antenatal clinic after 2 weeks and continue with
hematenics and avoid constipation
-persistent bleeding esp. uterus larger than expected
may indicate twins or molar pregnancy
Inevitable abortion
• Is a type of abortion at a stage that is irreversible
• Mother is anxious and worried due to fear of loss of
the pregnancy
• There may be heavy bleeding with clots
• C/o painful uterine action
• On V/E – using a speculum some clots may be seen
protruding
• At times membranes may rupture or may remain
bulging
• Signs of shock in case of severe bleeding
• Severe backache due to severe contractions
• Inevitable may follow threatened abortion
Management of inevitable abortion

• Take history; Amenorrhea, nature of blood, amount


and when it started
• Take vital observations and chart them
• Examine the mother to ascertain the gestation age
• Resuscitate with iv fluids if severely bleeding
• Keep her warm
• Give ABCs i.e. Ampicillin 1g,metronidazole 500g
stat, analgesics e.g. morphine 15mg can be given
• Reassure the mother and relatives of the inevitable
outcome
• If pregnancy is ˂16wks,plan for evacuation of
uterine contents, if evacuation not possible
immediately :
-Give ergometrine 0.2mg IM (repeated after
15min if necessary) or misoprostol 400mcg
PO(repeated once after 4hrs if
necessary):arrange for evacuation as soon as
possible
≥16wks: Await spontaneous expulsion of
products of conception and then evacuate
uterus to remove any remaining products
• If necessary infuse oxytocin 40unitsin 1L IV
fluids at 40 drops/min to help expulsion of
products of conception
Incomplete abortion

• Part of the products has been expelled.


• Continued painful contractions and bleeding.
• Generally dehydrated and anxious
• General condition depends on the amount of bleeding
if severe may have signs of shock, anemia.
• uterus is still bulky, tender due to retained products,
fundal height less than W.O.A as some products will
already have been expelled
• Some products may be seen protruding into the
vagina.
• Cervix is open with products
Management of Incomplete abortion
• ˂ 16weeks: if bleeding is light to moderate,use
fingers or sponge forceps to remove products of
conception protruding through the cx
• If bleeding is heavy, evacuate uterus:
 Manual vacuum aspiration (MVA) is preferred
method, sharp curettage should be done only if MVA
is not available
 If evacuation not immediately possible, give
ergometrine 0.2mg IM(repeated after 15min. If
necessary) or misoprostol 400mcg orally (repeated
once after 4hrs if necessary)
• Ensure follow up of the woman after treatment
≥ 16weeks

• Infuse oxytocin 40IU in 1 L IV fluids 40 drops/min


until expulsion of POC occurs
• Evacuate any remaining products of conception
from uterus by dilatation and curettage
• If necessary give misoprostol 200mcg vaginally 4
hourly until expulsion but do not administer more
than 800mcg
• Continue observing B.P,PR to exclude bleeding, shock

• Ensure follow up after treatment


Complete abortion
• All the POC are expelled and it usually occurs before
8 weeks of pregnancy.
• Pain and bleeding cease soon after the entire POC are
expelled.
• O/E – mother looks anxious, dehydrated and may be
anemic
• P/A; no or slight LAP, uterus well contracted, smaller
than the weeks of amenorrhea
• On V/E slight bleeding, cx is closed
• U/S uterus will be empty
• Mother may bring the expelled product so r/o if its
complete and Provide PAC
Management of complete abortion
• Evacuation not necessary
• Observe for heavy bleeding
• Ensure follow up after treatment
Missed abortion
Definition: applies when the embryo dies,
despite the presence of a viable placenta and
the sac is retained as the cervix remains
closed.
At times there a slight separation of the
placenta from the uterine wall then the fetus
dies but is not expelled
Signs and symptoms
• History of threatened abortion.
• C/O a dirty brown discharge (originating from
degeneration of placental tissue) that persists.
• Patient’s symptoms of pregnancy regress.
• The uterus fails to grow.
• No foetal heart motions are detected by U/S
• Coagulation defects (hypofibrinogenaemia)
are a complication
Management.
• Most patients abort spontaneously.
• Many women prefer the preg. Terminated.
• Rx
-Prostaglandins
-Dilatation & Curettage
Investigations
• U/S
• Bleeding and clotting time
Recurrent (Habitual) abortion

• Three or more consecutive diagnosed abortions.


• 2% of couples have recurrent abortions.
• The risk of further abortion increases with each
pregnancy lost
• Risk of preterm birth
• Causes of habitual abortion
Idiopathic causes
Structural uterine defects
– Septate uterus, submucous myomas, Cervical
incompetence.
Hormonal imbalance corpus luteum handing
over its functions to the placenta hence less
progesterone
Chromosomal abnormalities 5% of couples
with recurrent abortion
Maternal diseases e.g. syphilis, DM.
• Management
• It’s a doctor’s case so if in maternity center
refer to hospital in Gyn OPD
• Investigations that can be done; RPR, U/S,
urinalysis and RBS to r/o DM
• RX will depend on the cause
Cervical incompetence
• This is a painless dilatation of the cervix in the
second or early third trimester allowing the
bulging membranes through the cervical os
into the vagina.
• The causes are unclear although trauma to the
cervix during D &C or induced unsafe
abortion are predisposing factors.
• 20% of women with recurrent abortions in 2nd
trimester have CX incompetence
• H/O: recurrent abortions after 12 weeks.
– Start with painless leaking of amniotic fluid
– Delivery of foetus that is so immature to survive.
– treatment is cervical cerclage ( a non absorbable
suture is inserted at the level of the internal os, at
14weeks and is removed at 38weeks of gestation
or when labour begins
– 10% abort after cerclage, 10% prematures
Septic abortion
• This condition is most commonly a
complication of incomplete abortion or
commonly induced unsafe abortion and is due
to ascending infection
• Unsafe abortion - prolonged retention of
POC, incomplete or un sterile evacuation of
the uterus.
Symptoms & Signs of septic abortion

• Mother looks anxious and sick looking


• anemic if there is a lot of blood loss
• severe lower abdominal pain
• foul smelling PV discharge & PV bleeding
• some products may be seen in case of incomplete
abortion
• Uterus feels soft and bulky
• signs of pregnancy may be present
• high temp due to infection, high PR, rebound
tenderness i.e peritonitis, Guarding, shock, confusion
Mgt
• Isolate the mother
• Rapid essential history and do pelvic examination.
• Give IV fluids depending on the degree of shock,
maintain a fluid balance chart.
• Blood grouping and x-matching, Hb, WBC, platelet
count, high vaginal swab for culture and sensitivity
• Give IV broad spectrum antibiotics e.g.
cephalosporins and metronidazole.
• Patient can be transfused if necessary
• Evacuate the uterus under GA after initiating
antibiotics and resuscitation.
• Continue with nursing care
INDUCED ABORTION

• This may be therapeutic or illegal(unsafe)


• Therapeutic abortion: Termination of the
pregnancy before 28weeks of gestation to
preserve maternal health e.g. in Severe
hyperemesis gravidarum, Uncontrolled DM
e.t.c. If pregnancy is less than 16weeks D & C
is done, if more than 16weeks prostaglandins
may be used
COMPLICATIONS OF ABORTION

• Early complications.
• Infection- Sepsis.
• Perforation of uterine wall during D&C.
• Hemorrhage- shock, anemia
• Cervical laceration, stenosis
• Late complications.
• Infertility- failure to conceive due to endometrial
damage, hysterectomy
• Fistula formation
• Chronic pelvic pain
• Cervical incompetence
• Asherman syndrome - a condition where the
cavity of the uterus develops scar tissue
(adhesions) commonly due D&C
POST ABORTION CARE (PAC)

Definition

Post abortion care is an approach for reducing


morbidity and mortality from incomplete and
unsafe abortion and its complications and for
improving women's sexual and reproductive
health and lives
Post Abortion care

• Package needed to provide quality services to patients


after an abortion
• Essential elements of PAC:
1. Emergency treatment of incomplete abortion and
potentially life-threatening complications.
2. Post-abortion family-planning counselling and
services.
3. Links between post-abortion emergency services
and the reproductive health-care system. For
example, providers need to be alert to symptoms of
sexually transmitted diseases and provide the
appropriate treatment for them.
• Also, it may be possible to offer cervical
cancer screening at the time of treatment or to
provide referral to a facility where screening is
available.
• Finally, women treated for spontaneous
abortion may have special reproductive
healthcare needs, such as special follow up for
management of recurrent spontaneous
abortion.
4.Provision of abortion services within the
confinement of the law
Emergency post abortion care services

• For treatment of incomplete and unsafe abortion

• Resuscitation

• Manual vacuum aspiration

• Antibiotics

• Blood transfusion

• Analgesia

• Laparotomy/laparoscopy
The aims of counseling:

• Solicit and affirm women's feelings and provide


emotional support

• Ensure that women receive appropriate answers to


their questions

• Help women clarify their thoughts about their


pregnancy, incomplete abortion, treatment,
resumption of ovulation and reproductive health
future

• Address other concerns women may have


post abortion family planning
counseling and services
• Ensure that patients receive information and counseling on post abortion
contraception (including emergency contraception) before leaving the
hospital.

• All methods of contraception can be considered for use after abortion

• Contraception should be started early after an abortion

• Diaphragm and cervical cap should be delayed till 6 weeks after a 2nd
trimester abortion

• There is high risk of expulsion of intra uterine device and risk of infection if
inserted at the time of 2nd trimester abortion. (delay for 3 months if
infection is present).
Linkage to reproductive and other
health services
:
• This encourages providing post abortion women with reproductive and
other health services present in the hospital.

• STI/HIV prevention education, screening, diagnosis and treatment

• screening for sexual and/or domestic violence, and referral for


medical/social/economic services and support

• infertility diagnosis, counseling and treatment

• nutrition education and hygiene

• cancer screening and referral,


• other health services