Abortion Dr Adem.pdf

1. ABORTION
By Dr ADEM J.

2. •Loss/termination of pregnancy either
spontaneously or intentionally before 28 weeks
of gestation and the fetal weight is less than
1000g.
–Expulsion of immature, nonviable fetus.
•Unsafe abortion globally accounts for 13% of
maternal deaths and over 30% of maternal deaths in
Ethiopia.
•Can be spontaneous or induced.
•About 15% of clinically recognized pregnancies
end in spontaneous abortion.

3. SPONTANEOUS ABORTION
•Abortion occurring without medical or mechanical
means to empty the uterus, with no intervention.
•Occurring in about 15% of pregnancies.
•These losses are unpredictable and unpreventable.
•Most commonly due to fetal chromosomal
abnormality (About 50-60% are caused by
chromosome abnormalities).
•Following a miscarriage, the chance of having
another miscarriage with the next pregnancy is
about 1 in 6 (about 15%)

4. •Usually in the 1
st
trimester (>80 percent of
abortions occur in the first 12 weeks of
pregnancy).
•Abortion types by gestation age.
–Early trimester abortion : occurs before
12weeks (GA 12 weeks or less)
–Late trimester abortion : occurs after
12weeks (GA >12 weeks)

5. Etiology
Fetal causes
–Fetal chromosomal abnormalities
•Is the commonest cause of abortion
•50– 60% of the first trimester(early) abortions are due to
chromosomal abnormalities.
–The majority of these are numerical abnormalities like
trisomy.
–Chromosomal structural abnormalities infrequently
cause abortion.
•Autosomal trisomy
–The most frequently identified chromosomal anomaly
associated with first-trimester abortions.

6. Maternal causes
a)Infections:
•genital tract infection(STI- gonorrhea,chlamydia
trachomatis,treponema pallidum)
–Endometritis (usually mixed anaerobic )
•systemic infection with pyrexia & ToRCH syndrome
•Mycoplasma hominis
•Ureaplasma urealyticum

7. b)Anatomic defects
–Uterine disorders : that decrease or distort the size of the uterine
cavity
acquired uterine defects
Uterine myoma : usually do not cause abortion
–Placental implantation over or in contact with myoma
»placental abruption, abortion, preterm labor ↑
»location is more important than size
•Submucous myoma - cause the biggest problem
•Intramural
Previous uterine scarring
–D&C
–Myomectomy,C/S,Infection,TB
–Asherman’s syndrome

8. developmental uterine defects(Uterine
anomalies)
»Consequence of abnormal mullerian duct
formation or fusion
–Spontaneously
–Induced by in utero exposure to DES
(diethylstilbestrol)
»Uni/bicornuate Ux
»Septate Ux

9. •Incompetent cervix
–Painless dilatation of cervix in the 2
nd
or early in the 3
rd
trimester
–Unless effectively treated, tends to repeat in each
pregnancy
–Etiology
•Previous trauma to the cervix
–Dilatation & curettage
–Conization
–Cauterization
•Abnormal cervical development
–Exposure to DES in utero

10. c)Endocrine disorders :
•Diabetes mellitus
–The rates of spontaneous abortion & major congenital malformations
–If well controlled there does not appear to be an increase in
abortion rate
–If poorly controlled there is an increase in abortions and it
correlates with the glycosolated hemoglobin
–Poor glucose control → incidence of abortion↑
•Thyroid disorders : hypo/hyperthroidism
–Hypothyroidism
»Iodine deficiency associated with excessive miscarriages
»Thyroid autoantibodies → incidence of abortion↑
•PCOS
•Progesterone deficiency

11. d)Drug use and environmental factor
–Tobacco
•Heavy smoking ↑ Risk for abortion
–Alcohol
•Spontaneous abortion & fetal anomalies → result from frequent
alcohol use during the first 8 weeks of pregnancy
–Radiation
•In sufficient doses → abortifacient
–Contraceptives
•When IUD fail to prevent pregnancy → abortion↑
•Spontaneous abortion is the most frequent complication of pregnancy with an IUD in
place
–Environmental toxins
•Arsenic, lead, formaldehyde, benzene,DDT, ethylene oxide →
abortifacient

12. e)Immunological factors – autoimmune factors
–Recurrent pregnancy loss
–Blood group incompatility b/n the mother & fetus
•Imcompatibilily due to ABO, Rh
f)Physical trauma
–Major abdominal trauma → abortion↑

13. •Diagnosis of abortions
–Clinical : Hx, P/E(PV)
•Any women of reproductive age experiencing at least
two of the following symptoms should be considered
as a possible abortion patient.
–Vaginal bleeding
–Cramping and/or lower abdominal pain
–A possible history of amenorrhea
–U/S
•differential of varieties of abortion
–gestation sac,
–embryo status, fetal heart tones, fetus movement

14. •Clinical stages/classifications of spontaneous
abortion
–Threatened abortion
–Inevitable abortion
–Incomplete abortion
–complete abortion
–Missed abortion
–Septic abortion
oHabitual abortion

15. Threatened abortion
–Vaginal bleeding during 1
st
half of pregnancy
•Bleeding is frequently slight, but may persist for days or
weeks
–Symptoms
•Usually bleeding begins first
•Cramping abdominal pain follows a few hours to several days
later
•Presence of bleeding & pain
→ Poor prognosis for pregnancy continuation

16. Features
–Hx
•Vaginal bleeding – slight (usually mild)
•Abdominal cramp – no/mild
•No passage of tissue(POC)
–P/E : Good general condition
•PV
–Cervix : closed
–Uterus : consistent with GA (correct size for date)
–U/S :
which is essential for the diagnosis Shows the
presence of fetal heart activity

17. Inevitable abortion
–Abortion is inevitable when
•uterine bleeding is associated with strong uterine
contraction dilated cervix with part of the conceptus
sac bulging through.
•gush of fluid is accompanied by bleeding, pain, or fever,
abortion should be considered inevitable.
–A condition in which:
•Vaginal bleeding has been profuse
•The cervix has become dilated
•Abortion will invetably occur.

18. –History
•Heavy vaginal bleeding.
•with no passage of products conception
•Severe lower abdominal pain which follows the
bleeding.
–P/E
•Poor general condition.
•The cervix is dilated
•The uterus may be the correct size for date
–U/S  Fetal heart activity may or may not present

19. Incomplete abortion
–Expulsion of some but not all of the products of conception.
–The internal cervical os remains open
–History
•Heavy vaginal bleeding.
•passage of products of conception
•Severe lower abdominal pain
–Examinations
•Poor general condition.
•The cervix is dilating and products of conception is passing through
the os
•The uterus is small for date
–U/S

retained products of conception (RPOC)

20. Complete abortion
–Following complete detachment & expulsion of the
conceptus
–The internal cervical os closes
History
 Heavy vaginal bleeding which has been stopped.
 lower abdominal pain which follows the bleeding which
has been stopped.
Examination
 The cervix is closed
U/S
showed empty uterine cavity or PROP

21. Missed abortion
–Retention of dead products of conception in utero
–Most of missed abortions are diagnosed accidentally
during routine U/S in early pregnancy.
–In some cases there may be a history of :
Episodes of mild vaginal bleeding
Regression of early symptoms of pregnancy .
Stop of fetal movements after 20 weeks
gestation

•Examina
tion
The uterus may be small for date

22. –U/S (which is essential for diagnosis )
•diagnosed when U/S showed no evidence of
heart activity .
–No increase in fundal height
–Absence of FHT
–Regressions of signs of pregnancy.
–Most terminates spontaneously.
–Serious coagulation defect(DIC) occasionally
develop after prolonged retention of fetus.

23. Septic abortion
–abortion complicated by infection.
–This may be due to criminal interference
–Features :
•Poor general condition
•vaginal bleeding with passage of product of conception,
with or without history of evacuation.
•Features of pelvic infection i.e pyrexia , tachycardia ,
general malaise , lower abdominal pain
, pelvic
tenderness & purulent vaginal discharge .

24. •Complications of abortion
1.Hemorrhage --- shock
2. Complication related to surgical evacuation ie E&C and D&C.
–Uterine perforation- which may lead to rupture uterus in the
subsequent pregnancy.
–Cervical tear & excessive cervical dilatation – which may lead to
cervical incompetence.
–Infection – which may lead to infertility & Asherman's syndrome.
–Excessive curettage – which may lead to Adenomyosis
3. Rh- iso immunisation  if the anti –D is not given or if the dose is
inadequate .
4.Psychological trauma .

25. Management of Abortion
•Initial patient assessment
•History:
–Length of amenorrhea
–Bleeding (duration, amount)
–Cramping (duration and severity)
–Abdominal or shoulder pain
–Drug allergy
–History of interference and method employed
–Symptoms of infection

26. Physical examination
–Check V/S (T, PR, RR, B/P)
–Note general health of the women
–General systemic examination
–In abdominal examination
•check –bowel sound
•If abdomen is distended
•Location and severity of tenderness & rebound
tenderness.

27. Pelvic examination
•Remove any visible products of conception from the vaginal
canal or cervical OS
•Note

–The amount of bleeding
–The cervical dilation status
–Presence of foul smelling discharge
–Check for cervical laceration
•Bimanual examination
–Estimate size of the uterus
–Check for any pelvic mass
–Check for tenderness in the pelvis

28. •Laboratory Ix
–Pregnancy test
–CBC
–BG & Rh
–U/A
–U/S
–OFT
–Coagulation profile

29. Management principles
a)Management of life threatening complication if
any
–Shock -- Resuscitation (IV fluid)
–Infection(sepsis) – broadspectrum IV antibiotics
–Severe anemia – transfusion
b)Management of specific types
c)Management of complications of Rx of
abortions
d)PAC

30. Management of threatened abortion
1.Reassurance
•If fetal heart activity is present, most of the cases will
progress satisfactorily
2.Advice:
•Decrease physical activity – avoid heavy activity
–Strict bed rest is of no therapeutic value
•avoid intercourse, douching
–Analgesia
3. Anti- D: anti-D should be given to all Rh–ve, non-
immunised patients, whose husbands are Rh+ve

31. 4. ANC as high risk patients
•Because those patients are liable to late pregnancy
complications such as APH and preterm labour .
–Monitor progress
–Subsequent assessment
•Ultrasonography-for viability
–after death of conceptus uterus should be emptied.
–Ectopic pregnancy should be considered if gestational sac or
fetus are not identified.
–If signs of established pelvic infection –
evacuate the uterus after antibiotic coverage

32. Management of incomplete abortion
–Curettage (uterine evacuation)
Methods of Uterine evacuation:
–Determined by uterine size
–If uterine size < 14 weeks
•MVA/EVA
•E & C if cervix is open
–If uterine size > 14 week
•Oxytocin infusion
•E & C

33. •Complications of curettage
–Hemorrhage
–Infection
–Uterine perforation
–Cervical laceration or cervical incompetence from
excessive dilatation
–Asherman’s syndrome
–Intra abdominal injury

34. –NB:The following signs seen during uterine evacuation
indicate perforation.
•An instrument (sound, Cannula, Curette) extends beyond the
expected limit of the uterus.
•Fat or bowel is found in the tissue removed from in the
uterus
•Severe pain
•In apparent vital sign derangement (hypotension in the
absence of bleeding)
•Analgesics/anaesthetics for E&C and MVA
–Paracervical block with local anaesthesia
–Pethidine
–NSAIDs : ibuprophen,paracetamol,diclofenac

35. Management Of Complete Abortion
–Ways of confirming completeness
•Examine conceptus carefully for completeness
•Ultrasound to see retained tissue
•Documented completeness on referral paper
•If any doubt of completeness evacuate the
uterus
–Administer ergometine 0.5mg

36. Management of missed abortion
–Diagnosis: US, negative pregnancy test, absent foetal movement
–Options of treatment
Conservative treatment:  if left alone spontaneous expulsion
may be anticipated(for upto 3-4weeks)
Surgical evacuation of the uterus; by D & C: Indicated in 1
st

trimester missed abortion
•Evacuate the uterus by MVA if GA 12 or less weeks;
Medical termination of pregnancy: by Misoprostol (PGE1)
•Indicated in 1
st
& 2
nd
trimesters missed abortions.
Cytotec vaginal ( is the best) or oral tab. 200 μg, 2 tab/ 3
hrs/ up to 5 doses daily, which can be repeated next day if
there is no response in the first day
Subsequent surgical evacuation is needed in cases of RPOC
–High dose oxytocin infusion +/- prostaglandins

37. Management of septic abortion
–Antibiotics : Cephalosporin I.V + Metronidazole I.V
–Surgical evacuation of uterus  usually 12 hrs after antibiotic
therapy ( until a reasonable tissue levels of antibiotics have been
achieved )

38. PAC
•Intervention to manage complications of
abortion (spontanous or induced,safe or
unsafe)
•5 components
1.Treatment
•Emergency treatment of unsafe or incomplete
abortion and life threatening complications
•Anti D – to all Rh –ve, nonimmunised patients,
whose husbands are Rh+ve

39. 2. Contraceptives & posabortion FP services
–Ovulation may resume as early 2 weeks after an
abortion. Therefore, if pregnancy is to be prevented,
effective contraception should be initiated soon after
abortion
–To prevent unwanted Px
–To practice child spacing
3.RH services
–Rx of STI

40. 4.Counselling & explanation
a)Contraception (Hormonal, IUCD, Barrier)
–Should start immediately after abortion if the
patient choose to wait , because ovulation can occur
14 days after abortion and so pregnancy can occur
before the expected next period
b)When can try again :
– Best to wait for 3 months before trying again .
This time allow to regulate cycles and to know the
LMP, to give folic acid, and to allow the patient to be in
the best shape (physically and emotionally) for the
next pregnancy

41. c) Why has it happened
–In the fiIn the majority of cases there is no obvious cause
–In the first trimester abortion , the most common cause
is fetal chromosomal abnormality
d) Can it happen again
– As the commonest cause is the fetal chromosomal
abnormality which is not a recurrent cause , so the chance of
successful pregnancy next time in the absence of obvious cause is
very high even after 2 or 3 abortions

42. e) Not to feel guilty
–as it is extremely unlikely that anything the patient did can
cause abortion
–No evidence that intercourse in early pregnancy is harmful
–No evidence that bed rest will prevent it ..
5.Community & service provider partnership
–To prevent unwanted Px & unsafe abortion

43. INDUCED ABORTION
•Induced abortion is the medical or surgical
termination of pregnancy before the time of
viability.
•Can be therapeutic or elective

44. •Therapeutic abortion
–Interruption of pregnancy before viability for reasons of
impaired maternal health or fetal disease.
–Indication
•Continuation of pregnancy may threaten the life of women
or seriously impair her health
–Persistent heart disease after cardiac decompensation
–Advanced hypertensive vascular disease
–Invasive carcinoma of the cervix
•Pregnancy resulted from rape or incest
•Continuation of pregnancy is likely to result in the birth of
child with severe physical deformities or mental retardation

45. •Elective (voluntary) abortion
–Is interruption of pregnancy before viability at the
request of the woman but not for therapeutic
indications.
–Most abortions done today fall in to these
category.
–Counseling should be offered before elective
abortion.

46. •Technics Of Abortion
–Abortion can be performed medically or surgically.
–Anti d should be given to Rh negative mothers.
–Methods for abortion in the first trimester
•Vacuum curettage(MVA)
•Medical abortion
–Second trimester abortion
•Dilation and evacuation
•Labor induction methods(high dose oxytocin or
misoprostol)

47. •Medical abortion in the first trimester(upto 9
weeks)
–Three highly effective regimens
•Mifeprostone (RU-486) + misoprostol
–The first highly effective means
–200mg PO mifepristone + 800ug vaginal misoprostol
after 2days
•Methotexate + misoprostol
•Misoprostol alone
–Vaginal misoprostol 800ug initially, followed by 800ug at
24 hours, if needed

48. NEW LAW OF ABORTION IN ETHIOPIA
•Article 551 of the penal code of the FDRE
allows termination of pregnancy under the
following conditions:
1-termination of pregnancy by a recognized
medical institution within the period
permitted by the profession is not punishable
where:

49. A - The pregnancy is the result of rape or incest.
B - Tthe continuation of the pregnancy endangers
the life of the mother or the child or the health of
the mother or where the birth of the child is a
risk to the life or health of the mother; or
C - The fetus has an incurable and serious
deformity. Or
D - The pregnant women, owing to a physical or
mental deficiency she suffers from or her
minority, is physically as well as mentally unfit to
bring up the child.