ABORTION CLASS NOTES. The definition, cause and management

Abortion notes

1. MCH 320 ABORTIONS

2. GENERAL OBJECTIVE At the end of the presentation, students should demonstrate an understanding on the different types of abortion and be able to offer comprehensive care to prevent complications.

3. SPECIFIC OBJECTIVES Define abortion State the different causes of abortion. Describe the classification of abortion. List the signs and symptoms of specific types of abortion. Outline the management of different types of abortion. Discuss immediate and late complications of abortions.

4. INTRODUCTION Abortion is classified as one of the leading causes of maternal mortality in early pregnancy in Zambia. Abortion is generally considered to be among the safest procedures if conducted by skilled health personnel.

5. INTRODUCTION CONT . However, unsafe abortions result in approximately 70,000 (15%) maternal deaths and 5 million hospital admissions per year globally. An estimated 10 to 20 million illegal abortions are performed worldwide annually, and an estimated 100,000 to 200,000 women die as a result-about one in every 100.

6. INTRODUCTION CONT. These deaths account for 20% to 40% of all maternal deaths. (WHO, 2004). Abortion is the main cause of bleeding in early pregnancy. Other early causes include ectopic pregnancy, molar pregnancy, implantation bleeding, cervical lesions and vaginitis .

7. INTRODUCTION CONT. The majority of abortions occur in the 1 st trimester and are classified as early abortion; Those occurring after the 13 th week are known as late abortion (Cooper, 2003). Abortion can either be spontaneous or induced.

8. INTRODUCTION CONT. In medical terms, whether induced or spontaneous it is generally called abortion. Unsafe induced abortion is performed by various methods such as herbal abortifacients, use of sharpened tools, drug abuse and physical trauma.

9. INTRODUCTION CONT. These abortions are done without use of aseptic techniques and complicates into sepsis and severe haemorrhage. Safe abortions are those performed using aseptic techniques with no complications.

10. INTRODUCTION CONT. However, in issues of abortion, ethical and legal issues have to be considered. The woman has rights to decide about matters concerning her own body. She has right to life, right to privacy, right to information and education, right to decide whether or when to have children.

11. INTRODUCTION CONT. She can decide whether to terminate or continue with the pregnancy. As we focus on preventing complications related to abortion, women affected, their partners and the family at large need emotional support to cope with the loss.

12. INTRODUCTION CONT. In rendering quality maternal health care to women affected by abortion, there’s need to ensure that facilities rendering these services are well equipped with skilled human resource and essential materials.

13. DEFINITIONS Abortion is the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability before 28 th Week gestation in Zambia (MOH, 2011). Abortion is expulsion or extraction from its mother of an embryo or fetus weighing 500g or less (WHO, 2004).

14. CAUSES OF ABORTION There are various causes of abortion. The common causes are as follows: 1. MATERNAL CAUSES: These include the following maternal influences: Maternal Age – Women who are 30 years and above are at high risk because of degeneration of the ovaries leading to low levels of progesterone which maintains the pregnancy. Low levels of progesterone leads to abortion.

15. Causes cont.. Maternal infections – Bacteria, viruses and parasites invade the placenta and affect the metabolism of the placenta leading to early degeneration. Toxoplasmosis, cytomegalovirus, syphilis, Chlamydia and malaria are the common infections that can cause abortion. Structural abnormalities of the genital tract – Retroversion of the uterus, bicornuate uterus, bicornuate uterus and fibroids hinder the growth of the fetus.

16. CAUSES CONT.. Maternal diseases – conditions such as anaemia, hypertension, renal diseases, and cardiac diseases lead to placental insufficiency. Poor placental perfusion makes it weaker and eventually starts detaching causing abortion. Endocrine abnormalities – Poor development of the corpus luteum, inadequate secretory endothelium and low serum progesterone levels lead to failure of the pregnancy to be maintained.

17. CAUSES CONT… Incompetent cervix ; this is due to inadequate cervical collagen fibers which makes the cervical Os weak leading to failure of the cervix to contain the weight of the growing fetus. Conditions like previous induced abortions and congenital cervical defects are the main causes of cervical incompetence. Stress and anxiety this is due to the effects of stress hormones which cause vasoconstriction leading to reduced blood supply to the fetus.

18. CAUSES CONT.. Environmental/ social factors – Caffeine from coffee, nicotine from cigarette smoke cause vasoconstriction leading to poor placental and fetal perfusion causing abortion. Alcohol consumption leads to maternal malnutrition. Exposure to organic solvents such as lead and radiation.

19. CAUSES CONT.. 2. FOETAL CAUSES Malformation of the conceptus- due to chromosomal abnormalities accounts for 50% of abortion cases.  

20. CLASSIFICATION OF ABORTION   Abortions can either be: 1. Spontaneous 2. Induced abortion.

21. CLASSIFICATION OF ABORTION

22. 1. Types of Spontaneous Abortion Spontaneous Abortion also known as Miscarriage is defined as the involuntary loss of products of conception prior to 26 weeks (Cooper & Frazer 2006). Spontaneous abortion is the loss of pregnancy before fetal viability. The stages of spontaneous abortion may include: Threatened abortion - this is an abortion which is diagnosed when a pregnant woman presents with slight bleeding through an undilated cervix, (pregnancy may continue).

23. Types cont. b) Inevitable abortion - when the pregnancy can no longer continue and will proceed to incomplete or complete abortion. c) Complete abortion- this is when all products of conception are expelled from the uterus. d) Incomplete abortion- this is when part of the products of conception, usually the foetus is passed while the placenta and membranes are retained in the uterus. Incomplete abortion or any abortion performed under unhygienic environment can become septic.

24. Types cont … e) Missed abortion- this is an abortion where all products of conception are retained and the cervical Os is closed but the foetus is dead. f) Habitual abortion- a condition where a patient has experienced 3 or more consecutive spontaneous abortions.

25. 2. Induced abortion Induced abortion is a process by which pregnancy is terminated before foetal viability and can either be therapeutic or criminal. Induced abortion can also be complete or incomplete. If it is not performed under hygienic conditions it can become septic.

26. INVESTIGATIONS 1. History History of being pregnant - ask the woman about her last menstrual period to confirm pregnancy and its duration. Ask about the amount of bleeding and how many times she has changed her pads to rule out haemorrhagic shock. Severity of the lower abdominal cramping as it can be a sign of pending abortion.

27. INVESTIGATIONS CONT. 2. Blood tests Gravidex test confirms pregnancy by presence of HCG which is used as a basis for pregnancy test. It is produced by the placenta and is present in maternal serum from 8 to 10 days after fertilization. It prevents normal involution of the corpus luteum at the end of the menstrual cycle, if at 11 weeks, the levels of HCG are low, spontaneous abortion can result. It is highest at 14 weeks and reduces later in the second trimester.

28. Investigations cont. Blood for culture and sensitivity will confirm the increased leucocytes, the causative organism and its sensitivity if there is sepsis. Full blood count may show reduced hemoglobin due to haemorrhage and increased leucocytes count if there is infection. Rhesus group should be checked to rule out rhesus iso - immunization. 

29. Investigations Cont… 3. Ultra sound examination : A confirmatory test that will reveal: Gestational sac which will show that the patient was pregnant or has products of conception. If the gestation sac is empty, it signifies that the patient has an incomplete abortion. Absence of fetal heart sounds will signify intrauterine fetal death as in missed abortion.

30. SPONTANEOUS ABORTIONS   I ) THREATENED ABORTION Threatened abortion is diagnosed when a pregnant woman presents with slight bleeding through an undilated cervix (Sellers, 2008). Any vaginal bleeding in early pregnancy should be thought of as a threatened abortion until confirmed by abdominal scanning which can show the exact type of abortion. With good management the chances of the fetus to remain viable and the pregnancy to continue are high.

31. Signs and symptoms of threatened abortion History of amenorrhea Signs of pregnancy present Pregnancy test is positive. Height of fundus corresponds with dates With or without backache and lower abdominal pains resembling dysmenorrhea Vaginal bleeding may be scanty Cervical OS closed and the uterus is soft, with no tenderness when palpated.

32. Immediate management of threatened abortion History and physical examination is important to rule out the presence of pregnancy. Vital signs such as temperature should be done half hourly to rule out infection. Blood pressure is taken hourly to rule out haemorrhagic shock when there is hypotension. Rapid and feeble pulse will also signify shock. Increased respiratory rate will signify pain.

33. Mgt. threatened abortion 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. Give mild sedatives e.g. Phenobarbitone 60mg 8hourly to enable patient rest in bed.

34. Immediate management of threatened abortion If uterine contractions become stronger, analgesics such as pethidine100mg intramuscularly or morphine 15mg may be administered. 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.

35. 2. INEVITABLE ABORTION An abortion is inevitable when the pregnancy can no longer continue (sellers 2008). In inevitable abortion, the cervix is dilated and products of conception are yet to be expelled.

36. Signs and symptoms of inevitable abortion History of amenorrhea. Signs and symptoms of pregnancy present. Amniotic membranes may be felt bulging into the cervical canal or may be already ruptured. Cramping Lower abdominal pains and backache. The Cervical Os is dilated ( Os is open). Tissues (products of conception), clots may be seen in the vagina or protruding through the os . Vaginal bleeding may be excessive. In some cases the mother may present with signs of shock because of severe bleeding.

37. Management of inevitable abortion If pregnancy is less than 16 weeks: Plan for evacuation of uterine contents. If evacuation not immediately possible; Give ergometrine 0.2 mg IM (repeated after 15 min. if necessary) OR misoprostol 400 µg by mouth. Arrange for evacuation as soon as possible.

38. Management of inevitable abortion If pregnancy is greater than 16 weeks: Await spontaneous expulsion of products of conception and then evacuate uterus to remove any remaining products of conception If necessary, infuse Oxytocin 40 units in 1 L IV fluids at 40 drops/min. to help expulsion of products of conception. Ensure follow up after treatment.

39. 3. COMPLETE ABORTION An abortion is complete when all the products of conception, which is the embryo or fetus and the placenta with intact membranes, are expelled from the uterus (Sellers 2000).

40. Signs and symptoms of complete abortion History of amenorrhea Signs and Symptoms of pregnancy regresses Abdominal pains and backache subside steadily. Uterus firm and well contracted History of passage of the products of conception An empty cavity is seen on ultrasound examination Diminishing or Minimal bleeding per vagina Cervical os closed.

41. Immediate management of complete abortion Rest in bed, if possible with sedation. Evacuation of the uterus is usually not necessary. Observe for heavy bleeding. Curettage only needed if bleeding persists. Check Hb after 24hours in case of severe anaemia due to severe bleeding.  

42. 4. INCOMPLETE ABORTION Is one in which part of the products of conception, usually the fetus is passed while the placenta and membranes are retained (Sellers 2008). The cervix is usually open. There is usually profuse bleeding as the uterus cannot contract and retract effectively due to the products of conception being retained in utero. Incomplete abortion when unattended to causes fatal complications.

43. Signs and symptoms of incomplete abortion History of amenorrhea. Severe and Cramping lower abdominal pains and backache. Abdomen soft, height of fundus does not correspond with dates. The uterus may feel bog and not well contracted. Heavy and profuse vaginal bleeding

44. Signs and symptoms of incomplete abortion Passage of some products of conception usually the fetus and the placenta and membranes are retained, some tissue may be present at the cervical OS. Signs of shock such as cold clammy skin, thread pulse, hypothermia, hypotension may be seen.

45. Immediate management Before 16 weeks Gestation; If bleeding light to moderate, use sponge holding forceps to remove products of conception protruding through cervix. If bleeding heavy, evacuate uterus: Manual vacuum aspiration (MVA) is preferred method, evacuation by sharp curettage should only be done if MVA not available

46. Immediate management After 16 weeks Gestation; Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until expulsion of products of conception occurs. Evacuate any remaining products of conception from uterus by dilatation and curettage. If necessary, give misoprostol 200 µg vaginally every 4 hours until expulsion, but do not administer more than 800 µg

47. Immediate management Replace blood if necessary or if the hemoglobin level is below 5grams. Antibiotics to prevent infection. If patient is in shock start a plasma expander for example dextran 50%, heamacil , drip after taking blood for grouping and cross-matching. Give ergometrine 0.5mg intramuscularly. Once these steps have been taken the condition usually improves and the patient can safely be transferred to hospital and ensure follow up.

48. Management cont. NOTE : Do not transfer a patient with haemorrhagic shock to the hospital; Resuscitate first to prevent complications.

49. 5. MISSED ABORTION This occur when the fetus dies and is retained in utero, together with the placenta and membranes ( Ladewig 1996). Signs and symptoms History of amenorrhea Signs of pregnancy disappear Height of fundus less than expected because the uterus does not grow. Brownish vaginal discharge. Cervical OS closed.

50. S/S of missed abortion There is no pain. Fetal movements if felt before ceases. Fetal heart cannot be heard by either fetoscope or Doppler Pregnancy test usually is negative

51. Immediate management A uterine evacuation is performed if the patient is less than 16 weeks pregnant. If the patient is more than 16 weeks pregnant, an oxytocin or prostaglandin infusion is erected to expel the fetus. If the condition of missed abortion persists for over 6-8 weeks, disseminated intravascular coagulation (DIC) disorders can occur, therefore, weekly blood samples are taken so that estimates of plasma fibrinogen can be made.

52. DIC comes about when a dead foetus is retained in utero for more than 3 to 4 weeks. Thromboplastins are released from the dead foetal tissues. These enter the maternal circulation and deplete clotting factors.

53. 6. BLOOD MOLE This condition arises in cases of missed abortion. The ovum dies in utero , and the decidua capsularis remains intact. The zygote is surrounded by layers of blood, due to bleeding between the gestational sac and the uterine wall. It usually occurs before the 12 th week of gestation. The signs of pregnancy disappear and there is a brown discharge present. When fluids drain from the blood mole, the fleshy, firm, hard mass which is left, is known as a carneous mole.

54. Immediate management An evacuation of the uterus is performed if it is diagnosed before 12 weeks, and oxytocics or prostaglandins are used to abort the mole if the condition is diagnosed after the 12 th week of pregnancy.

55. 7. 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 ( Ladewig 1996). There is usually no obvious cause but the commonest predisposing factors are uterine abnormalities and cervical incompetence. Diabetes mellitus also can cause recurrent abortions if not well managed.

56. Habitual abortion cont. These women should always be referred to the hospital . To enable the cervix hold the weight of the growing foetus and ensure sustenance and viability of the pregnancy, the doctor can insert a shirodkar suture .

57. INDUCED ABORTION Induced abortion can either be; Therapeutic abortion, or Criminal abortion leading to septic abortion.  

58. 1. THERAPEUTIC ABORTION A therapeutic abortion is one in which the uterus is evacuated by a qualified, trained medical doctor, for a valid medical reason (Sellers 2008). Therefore this procedure must only be performed in the interest of the mother’s life and her total well- being.

59. It can also be done if there is increased chance of gross fetal abnormalities. It is only carried out in a hospital where haemorrhage can be effectively controlled, resuscitative facilities are at hand and where strict aseptic measures are always taken. The consent of the medical superintendent of the hospital is required by law, as well as the consent of the patient and her husband or guardian if she is less than 18 years.

60. Immediate management Evacuation of the uterus if pregnancy is less than 16 weeks done under strong analgesia given before the procedure, if the pregnancy is more than 16 weeks oxytocin and cytotec is given to expel the products of conception. Psychological care is given throughout the procedure to gain cooperation.

61. Immediate management Complete bed rest is essential. Observe the blood loss through pad count to assess the amount of blood loss to prevent shock. Drugs like Benzylpenicillin , Gentamycin and Metrodidazole are given to combat and prevent infection.

62. 2. CRIMINAL ABORTION This is an abortion which is illegally procured (Sellers, 2008). It is usually performed by a unqualified person, possibly under unhygienic conditions. Methods like use of herbal medicine taken orally or inserted in the vagina and use of sharp objects introduced from the vagina to the uterus with an intention of disturbing the uterine environment to induce abortion.

63. Criminal abortion cont. This type of abortion can lead to incomplete or septic abortions. If it is incomplete then it should be treated as incomplete abortion as described above with an antibiotic cover to combat infection.

64. 3. SEPTIC ABORTION A Septic abortion can follow any incomplete abortion, but is more often associated with a criminal abortion (Sellers, 2008). Therefore if infection is disseminated into the systemic circulation is called septic abortion. Any abortion where aseptic techniques are not followed can lead to sepsis.

65. Signs and symptoms of septic abortion History of amenorrhea History of abortion usually unsafe abortion General discomfort Pyrexia usually >38°C, Headaches Tachycardia Severe pain around the supra pubic region. Uterus bulky and very tender on palpation Foul smelling vaginal discharge usually profuse.

66. Signs and symptoms of septic abortion Cervical OS open and products of conception may be felt in the cervical canal. Chills and fever signifies serious infection. Generalized abdominal tenderness with rebound tenderness, rigidity or distension are signs of spreading peritonitis. Jaundice is often present. Patient feels weak and seems extremely ill. Cervical motion elicits severe tenderness.

67. Immediate management 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; however treatment should be instituted as soon as the diagnosis is made. Most serious complication of septic abortion is septic shock characterized by hypotension with tachycardia, normal or subnormal temperature. Therefore the following should be instituted. Resuscitate with intravenous fluids in order to replace lost fluids.

68. 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). Evacuation of the uterus should be instituted immediately resuscitation is complete.  

69. POST ABORTAL CARE (PAC)

70. POST ABORTAL CARE This is the care that is given to a patient who has had an abortion. ELEMENTS OF POST ABORTAL CARE Post abortal care is anchored on 3 main elements. These are; 1. Emergency treatment of incomplete abortion and potentially life threatening complications. 2. Post abortion family planning counseling and services. 3. Links between post abortion emergency services and the reproductive health care system.  

71. 1. EMMERGENCY TREATMENT First, confirm the occurrence of an abortion by rapid and correct assessment. Identify complications and treat them to avoid deterioration of the patient’s condition. Talk to the woman about her obstetric condition and institute the treatment plan making sure that she is fully involved. Do a Speculum examination to determine cervical dilatation, damage or tears in the vagina and cervix, amount of bleeding and any products of conception which may be visible in the vaginal canal or at the cervix.

72. Avoid vaginal examination as it can worsen the bleeding and complicate the condition. Do abdominal examination to check for distention, masses or rebound tenderness. Also done to determine the size, consistency and position of the uterus. In inevitable or incomplete abortion, uterine evacuation to remove retained products of conception must be instituted. Stabilise the woman and refer urgently if you are unable to offer post abortal care services.

73. Two main approaches in the management of abortions are surgical and medical management. SURGICAL MANAGEMENT Dilatation and Curettage (D and C). Manual Vacuum Aspiration (MVA )

74. 1. DILATATION AND CURETTAGE Involves the use of a curette to scrap the walls of the uterus in order to remove the retained products of conception. The cervix is dilated with use of a prostaglandin (Misoprostol). The patient is given general anaesthesia or paracervical block. Ergometrine 0.5mg is also given iv during the operation. (Sellers, 2008). Nowadays, the use of D & C is no longer encouraged due to its adverse effects such as severe trauma, severe haemorrhage and increased chances of infection.  

75. 2. MANUAL VACUUM ASPIRATION (MVA) This is the surgical method involved in the treatment of incomplete abortion which is done to evacuate the remaining products of conception. It is a safe and effective alternative method of uterine evacuation. It is widely employed in preventing complications of incomplete and unsafe abortions.

76. MVA uses suction to remove uterine tissue through a cannula with minimal scrapping of the uterine walls. The suction may be electrical, foot or hand by a specially designed MVA syringe. Incomplete abortion in the late second trimester should be done by an experienced physician with advanced training in an equipped facility with an emergency backup system to administer IV fluids, Blood Transfusion, and perform abdominal surgery.  

77. Preparation for MVA Observe principles for infection prevention to minimize risks of infection. Have all equipment readily available. Woman’s bladder should be emptied. Perineum should be washed with soap and water or vulva swabbing should be instituted. Explain the procedure to the woman and offer psychological support. NOTE: Shaving the patient’s pubic hair may increase the risk of local and disseminated infection. If pubic hair is long & interferes with the instruments, trim with scissors.

78. STEPS FOR PERFORMING MVA STEP 1 Wash hands and put on sterile gloves. Gently insert the speculum and check the cervix for tears and protruding products of conception (POCs). If POCs are present in the vagina or cervix remove using the sponge holding forceps. Insert the speculum per vargina and secure it in place. STEP 2. Clean the cervix and vagina with an antiseptic solution.

79. STEP 3. Administer Para cervical block and grasp the cervix with a tenaculum. STEP4. Cervical dilatation is necessary only when the cervical canal will not allow the cannula selected for use. STEP 5. While holding the Cervix steady with a tenaculum and gently applying traction, insert the cannula through the cervical os into the uterine cavity.  

80. STEP 6. Push the cannula slowly into the uterine cavity until it touches the fundus, but not more than 10cm. STEP7. Attach the prepared MVA syringe to the cannula STEP8. Release the pinch valves to transfer the vacuum through the cannula to the uterine cavity. STEP 9. Evacuate the POCs by gently rotating the syringe from side to side (10 to 2 O'clock rotation) and then moving the cannula gently & slowly back and forth within the uterine cavity.

81. STEP 10. Check for signs of completion which are red or pink foam and no more tissue seen in the cannula , a gritty sensation is felt , the uterus contracts & grips the cannula. STEP 11 Withdraw the cannula, disconnect from MVA syringe, open the valves & empty the contents into the strainer. STEP 12. Quickly inspect the tissue removed from the uterus. NB: absence of products of conception with symptoms of pregnancy raises a strong possibility of an ectopic pregnancy. When this occurs, re-evaluate the patient.

82. STEP 13. Remove the forceps & speculum from the vagina and perform a bimanual exam to check size & firmness of the uterus. STEP 14 Insert speculum to check for bleeding. STEP 15 Check the vital signs to rule out signs of shock such as hypotension. STEP 16 Process metal instruments by autoclaving and plastic instruments by high level disinfection. Wash hands thoroughly and dry them.

83. ADVANTAGES OF MVA Access to MVA services is increased because these services are offered at the primary health care facilities. The cost of post abortal services is reduced because severe complications are prevented. The resources used are reduced. Risk of post-evacuation complications is reduced. Less expensive, reusable equipment is used. In comparison to dilatation and curettage; it causes less trauma to the patient. there is minimal bleeding and reduced chances of sepsis. It does not require anesthesia and can be done in the examination room.

84. Pain management in MVA MVA is a very painful procedure and it is performed on patients who are fully awake. Pain management aims at making the patient experience minimum of anxiety and discomfort as well as the less risk to health care provider. Verbacaine is given in form of psychological reassurance. Strong analgesia such as Pethidine is administered. In some instances Sedatives such as Diazepam is given to calm the woman down. These interventions are used depending on the needs assessment.  

85. Complications of MVA Uterine perforation Cervical perforation Air embolism Severe vaginal bleeding Shock  

86. MEDICAL MANGEMENT/INTERVENTION The Drug called Misoprostol (Cytotec) is used in the treatment of incomplete abortion. This is mostly used in the late 2 nd Trimester. Misoprostol 600 mcg oral, OR Misoprostol 400 mcg sublingual Side effects of Misoprostol Diarrhoea abdominal pain, dyspepsia, flatulence, nausea Vomiting rashes, dizziness.

87. OXYTOCIN: 10 -40 iu in an infusion of 500mls of normal saline. Side effects: nausea, vomiting; arrhythmia; headache; rarely disseminated intravascular coagulation, rash, and anaphylactic reactions, hypotension, uterine spasm, uterine hyperstimulation, or May lead to hypertonicity, tetanic contractions

88. ERGOMETRINE: 0.2 - 0.5mg IM. Side effects: nausea, vomiting, headache, dizziness, tinnitus, abdominal pain, chest pain, palpitation, dyspnoea, bradycardia, transient hypertension, vasoconstriction; stroke, myocardial infarction and pulmonary oedema.

89. 2. POST ABORTION FAMILY PLANNING Because ovulation returns rapidly following an abortion, post abortion family planning services need to be initiated immediately. Ovulation may occur by day 11 post abortion. 75% of women will have ovulated within 6 weeks post abortion.  

90. Essential components of Post abortion family planning. Give adequate information and education as well as counseling about available family planning methods. Screen clients thoroughly and bear in mind the precautions. Give woman ample time to make a choice. Assurance the woman of constant supply of contraceptives.

91. Emphasise the importance of follow-up care. Reinforce safer Sex practice education and protection against sexually transmitted infections and HIV. Base the education and counseling on individual assessment the woman’s clinical condition, personal characteristics, needs and reproductive goals. Put into consideration the service delivery capabilities where she receives treatment and in the community where she lives.

92. FAMILY PLANNING METHODS TO USE AFTER ABORTION. All modern methods are acceptable provided that: Thorough counseling is given to ensure voluntarism and choice Clients are screened for precautions.  

93. Method When to Start Remarks Hormonal     Immediate Can be started even if there is infection or anemia Condom IUD Less than 12 weeks More than 12 weeks Immediate or delayed 4–6 weeks after abortion If there is infection, delay until it clears. If hemoglobin is less than 7 g/ dL , delay until it improves. Give an interim method. Similar to postpartum Tubal Ligation Immediate Delayed Clean procedure If infection or hemoglobin is less than 7 g/ dL

94. 3. LINKS TO OTHER REPRODUCTIVE HEALTH Linkages of post abortion care services with reproductive health services are essential in improving the reproductive health status of women. Lack of linkages contributes to women’s continued poor health status and negative outcomes.

95. EXAMPLES OF OTHER REPRODUCTIVE HEALTH SERVICES   Treatment of sexually transmitted infections Cervical cancer screening for women over age who are sexually active. Infertility services Pre-pregnancy advice (e.g., nutrition, immunization, management of existing medical conditions)

96. FOLLOW-UP AFTER AN ABORTION Women treated for spontaneous abortion may have special reproductive health care needs, such as special follow-up for management of habitual abortion (infertility) or advice before attempting to become pregnant again or about prenatal care. Reassure the woman that chances for a subsequent successful pregnancy are good unless there has been sepsis or unless cause of abortion is identified that may hurt future pregnancies. Encourage her to delay the next pregnancy until completely recovered Provide counseling for women who have had unsafe abortions.    

97. COMPLICATIONS OF ABORTION. Shock Haemorrhage Sepsis Anaemia Intrauterine / Intra abdominal injury Infertility

98. Termination of Pregnancy Act, 13 October 1972. Abortion is legal in Zambia. The act states that; ‘’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, one of whom has specialised in the branch of medicine related to patients condition’’

99. Under Zambian Law, termination of pregnancy can be done if; There is risk of injury to the physical or mental health of the pregnant woman; or  Risk of injury to the physical or mental health of any existing children of the pregnant woman; or  Risk that if the child were born it would suffer from severe physical or mental abnormalities as to be seriously handicapped.

100. CONCLUSION Abortion is among the main causes of maternal mortality globally. All cases of abortions must be treated promptly. Chances of abortions are reduced if women seek early treatment. Post abortal care facilities must be evenly distributed Increased material and skilled human resource ensures quality care.  Community sensitization on the dangers of criminal abortions. Family planning services will tremendously reduce the impact of unsafe abortion. All stakeholders to come on board so that maternal morbidity and mortality rates are reduced.  

101. References Diane Fraser et al, (2003) Myles Textbook for Midwives , 14 th Edition, Churchill Livingstone, Toronto, Canada. Judith Winkler et al, (1995) Post Abortion Care, A reference manual for improving quality of care, Post abortion care consortium, USA. Pauline McCall Sellers, (2008) Midwifery Volume 2, Juta and Co Ltd, RSA Ladewig Wieland (1996), Maternal New born Nursing , 5 th Edition, Benjamin Publishing Co, Inc , California, USA.