Abortion Dr Asheber G aym.pdf

1. Abortion
Asheber Gaym M.D.
January 2009

2. Outline
•Define abortion
•Brief epidemiology of abortion
•Discuss different categories of abortion
•Discuss etiologies of abortion
•Discuss clinical types of abortion
•Outline diagnosis of abortion
•Outline the management of abortion
•Describe complications of abortion

3. Brief Epidemiology of Abortion
•Spontaneous abortion complicates 10-20% of
pregnancies
•Incidence of induced abortion varies from country to
country based on the availability and accessibility of
contraception
•WHO estimates that there are 80 million abortions
annually of which 40% are unsafely induced
•Nearly 80,000 maternal deaths (20% of total annual
global maternal mortality) is due to unsafe abortions

4. Definition of abortion
•Abortion (miscarriage) is termination of pregnancy before
fetal viability.
•Fetus acquires potential viability starting from a gestational
age of 24 weeks, when the alveolar development and
surfactant production begins in the fetal lungs.
•WHO considers a gestational age of 20 weeks as the cut off
for fetal viability and thus for the definition of abortion
versus delivery
•Different countries use different gestations upto 28 weeks
to consider fetal viability
•A fetal weight of 500 grams or (1000 grams in those who
use a cut of gestation of 28 weeks) is also considered as the
cut off for differentiating abortion from delivery

5. Categories of Abortion
•Based on etiology – Spontaneous versus Induced
abortion
•Based on gestational age – Early (less than 12
weeks) versus Late abortion(greater than
12weeks) – late abortions have more
complication risk than early abortions
•Based on clinical presentations – Different clinical
types
•Based on site of termination in induced abortions
– Safe versus unsafe abortion ( performed by
unskilled person on in an ill equipped setting)

6. Etiologies of Spontaneous Abortion
•Genetic abnormalities – upto 60%
–Chromosomal – trisomies, monosomies, deletions,
translocations etc
–Gene defects
•Infections
–Maternal infections – e.g. malaria, pyelonehpritis etc
–Perinatal infections – e.g. syphilis, mycoplasma, ureaplasma etc

•Uterine factors
–Uterine myomata
–Mullerian abnormalities or defects – septate, bicornuate uterus
etc
–Cervical incompetence

7. •Endocrine abnormalities
–Hypothyroidism ; hyperthyroidism
–Uncontrolled diabetes mellitus
–Luteal phase defects
•Immunological factors – autoimmune diseases
–Antiphospholipid syndrome
•Abdominal trauma

8. Clinical types of abortion
•Threatened abortion
–Minimal vaginal bleeding and lower abdominal
cramps
–Closed cervix and uterine size comparable to
gestational age
–Viable fetus
–60-80% continue the pregnancy
•Inevitable abortion
–Heavier vaginal bleeding and more severe cramps
–Open cervix but no expulsion of conceptus yet
–Leakage of liquor even without open cervix

9. Clinical types of Abortion
•Incomplete abortion
–Features of inevitable abortion with additional
feature of expulsion of conceptus parts outside
the cervix
•Complete abortion
– complete expulsion of all conceptus parts which
are identified by provider including the fetus,
placenta, membranes and cord
–Uterus well contracted and cervix closed
–Cessation of vaginal bleeding

10. Clinical types of Abortion
•Missed abortion
–Initial symptoms of abortion subside with cessation of
vaginal bleeding and uterine contractions
–Regression of symptoms and signs of pregnancy
–Retention of conceptus within the uterus for more than two weeks
–Closed cervix and uterine size less than calculated weeks of
amenorrhea
•Recurrent (habitual) abortion
– Three or more consecutive abortions
•Septic (infected) abortion
–Any of the abortion types complicated by infection

11. Diagnosis of Abortion
•Diagnosis of a pregnancy less than fetal viability
•Symptoms
–Vaginal bleeding
–Abdominal cramps
–Leakage of liquor or expulsion of conceptus
–Regression of pregnancy symptoms in missed abortion
•Signs
–Hemodynamic instability
–Vaginal bleeding
–Cervical changes and reduced uterine size
–Visualization of expelled conceptus

12. Diagnostic workup of a suspected abortion
•Hemoglobin ( hematocrit)
•Blood group and RH type
•Pregnancy test if necessary
•Ultrasonography to document fetal viability
•Blood cross match if necessary
•In cases of septic abortion – as required
–WBC and differential
–Coagulation profile
–Liver and renal function tests
–PO2, PCO2 etc as necessary

13. Management of Abortion
•Depends on:
–Clinical type of abortion
–Gestational age: early versus late
–Presence or absence of infection
•Elements of abortion management:
–Medical/surgical management of abortion
–Post abortion family planning
–Counseling
–Linkages with other reproductive health services
–Community partnerships and involvement

14. Medical/Surgical Management
•Threatened abortion
–Bed rest, avoidance of coitus
–Advice to return if heavy bleeding or passage of
conceptus
•Inevitable abortion
–Early – Suction curretage (manual vacuum aspiration)
–Late- Expel conceptus with oxytocin drip and
supplement with curretage as required
•Incomplete abortion
–Early – Suction curretage
–Late – Suction or metallic curretage as convinient

15. Medical/Surgical Management
•Missed abortion
–Early – Suction curretage
–Late- Expel conceptus with oxytocin drip and follow up
with curretage as required
•Recurrent abortion
–Manage accordingly and investigate for possible causes to
avoid recurrence
•Infected or septic abortion
–Cover with broad spectrum antibiotics to cover both gram
positive as well as gram negative aerobic and anaerobic organisms
–Pelvic infections are often polymicrobial

16. Linkages with other RH services
•Reproductive health problems that are
common in clients requiring abortion care (
particularly unsafe) include:
–Sexually transmitted infections including HIV/AIDS
–Gender based violence including sexual assault
–Family planning
–Infertility
–Reproductive tract cancers particularly cervical ca
–Counseling

17. Complications of Abortion – Before or during
care provision
•Heavy bleeding and shock
•Uterine perforation
•Infection and sepsis
•Infertility later in life – tubal/ Ashermann’s
•Ectopic pregnancy later in life
•Psychological trauma – depression