Department of Gynaecology ABORTIONS.pptx

In depth discussion on abortions and it management

1. ABORTIONS PRESENTER: DR KATUPISHA MODERATOR: DR LUWAILE

2. OUTLINE Definition Incidence Classification Etiology Types Treatment

3. DEFINITION Abortions is the expulsion of an embryo or fetus weighing 500g or less, incapable of independent survival . ( WHO ). The term miscarriage is the recommended terminology for spontaneous abortion . A bout 10-20% of pregnancies end in miscarriage and another optimistic figure are induced illegally

4. CLASSIFICATION Spontaneous and induced abortion . Induced abortion (intentional) Legal Illegal induced abortion ( unsafe).

5. Induced abortion Methods Surgical Suction curretage up to 12 completed weeks Medical Up to 12 weeks gestation mifepristone and prostaglandins (recommended) Methotrexate and misoprostol Misoprostol only Prostaglandins induction after 12 weeks+/- oxytocin

6. Law and therapeutic abortion in Zambia Abortion is legal in Zambia 2 doctors must agree to patient’s request This is done if continuation of pregnancy must: 1. Endanger the life of woman 2. Endanger the physical or mental health of woman 3. Endanger mental or physical health of siblings 4. Involve a risk that the fetus would be handicapped

7. Etiology Fetal factors Maternal factors Unexplained

8. Etiology Foetal factors Chromosomal abnormalities(50% ), aneuplodies ,monosomy X,Triploidy Trisomy 16 : mc autosomal trisomy,lethal Abnormalities arise de novo Congenital anomalies Trauma: invasive prenatal diagnostic procedures

9. Maternal factors Endocrine and metabolic(10-15%) Luteal phase defect(LPD) Deficient progesterone secretion from the corpus luteum or poor endometrial response to progesterone Thyroid abnormalities: Overt hypothyroidism or hyperthyroidism Diabetes mellitus poorly controlled

10. Maternal factors Anatomical factors (10-15%) Cervical incontinence Congenital malformations of the uterus. Uterine Fibroids Intra uterine adhesions

11. Maternal factors Infections (5%) Viral Rubbella , cytomegalo , variola , vaccinia Parasitic toxoplasma,malaria Bacterial chlamydia, brucella .

12. Maternal factors Autoimmune disease A ntibodies against own tissue and placenta . Medical illness. Cyanotic heart disease. Hemoglobinopathies are associated with early abortion Blood group incompatibility ABO Rhesus

13. Investigation FBC Rhesus group should be checked DCT TORCHS screen Urinary LH

14. Investigation Lupus anticoagulant and anticardiolipin antibodies HCG beta unit-doubles by 50% in 48 hours in normal pregnancy Thyroid function Karyotyping of both parents Radiological Hysteroscopy Pelvic ultrasound - will show if fetus is in uterus and is viable-if doubt repeat a week later

15. Maternal Factors Environmental Factors Cigarrete smoking, alcohol Unexplained Causes

16. Mechanism of miscarriage In early weeks death of ovum occurs first, followed by its expulsion. In the later weeks, expulsion of the fetus which may have signs of life but too small to survive. Before 8 weeks :The ovum surrounded by villi with the decidual coverings is expelled out intact . 8-14 weeks; expulsion of the fetus is commonly occurs leaving behind the placenta and the membranes . Beyond 14 weeks; process of expulsion is like mini labor. The fetus is expelled first followed by expulsion of the placenta

17. Types of miscarriages Threatened miscarriage The process of miscarriage has started but recovery is possible . Clinical features: Bleeding per vaginum is usually light and may be brownish or bright red in color. Usually painless Uterine size correct for dates Cervix is closed

18. Treatment No specific treatment (self limiting condition) Excessive work is discouraged Avoid coitus Progestogens if bleeding persists

19. Inevitable abortion The changes have progressed to a state where continuation of pregnacy is impossible . Features Amenorrhea followed by heavy vaginal bleeding Pain follows bleeding Uterus may be small , large or correct size for dates Cervix is dilating and POC may be passing

20. Management Less than 13 MVA with analgesia D & C More than 13 expedite expulsion with oxytocin if absent membranes Analgesia ,antibiotics. Evacuation of retained RPOCS after expulsion. Send specimen for histopathology Post abortal care

21. Complete miscarriage When the products of conception are expelled completely Clinical features: History of expulsion of fleshy mass per vaginum . Vaginal bleeding becomes trace or absent. Uterus smaller than the period of amenorrhea C ervical O s is closed Examination of the expelled fleshy mass is found complete .

22. Incomplete abortion Products of conception not entirely expelled . Clinical features. History of expulsion of a fleshy mass per vaginum followed by lower abdomen pain. persistence of vaginal bleeding. patulous cervical os often admitting a tip of a finger .

23. Management Medical Misoprostol Surgical MVA with analgesia D & C PAC

24. Missed abortion T he fetus is dead and retained inside the uterus for a variable period Features: Amenorrhoea which may or may not be followed episode of slight vaginal bleed Regression of earlier signs and symptoms of pregnancy Uterus small for dates ,cervix os closed

25. Management Conservative- if left alone ,resorption or spontaneous expulsion will occur Active management options <12 weeks Medical treatment Evacuation under analgesia >12 weeks use vaginal prostaglandins to induce abortion

26. Septic abortion Incomplete abortion complicated by infection Abortion is usually considered septic when there is Rise in temperature of at least 38 for 24 hours or more. Offensive or purulent vaginal discharge Other evidences of pelvic infections such as lower abdominal pain and tenderness .

27. Pathogenesis Common organisms are; E.coli and other gram negative, strep ( haemolytic and anaerobic), other anaerobes ( eg bacteroides ) and staphylococcus. Cl. perfringes and cl. tetani rare but lethal Investigations include: Swabs for M/C/S, Coagulation status, FBC/DC KFTs, LFTs

28. Clinical grading; Grade 1 the infection is localized in the uterus Grade 2 the infection spreads beyond the uterus, to the parametrium , tubes, and ovaries or pelvic peritoneum. Grade 3 generalized peritonitis and or endotoxic shock or jaundice or acute renal failure.

29. M anagement Adequate resuscitation; IV fluids and/or BT 3 rd generation antibiotics start ideally 8 hours pre MVA and for total of 14 days MVA by experienced practitioner increased risk of perforation Send specimen for histopathology Watch out for coagulopathy.

30. Recurrent Abortion A sequence of three or more consecutive spontaneous abortion before . Preventive measures to be taken (depending on cause) Encourage expecting mothers for early antenatal care Full septic screen during first antenatal visit Cervical cerclage for women with cervical incompetence Manage underlying condition e.g HTN , DM etc

31. References Dutta’s Textbook of gynecology 7 th edition. Medscape Phillip N Baker(2006),Obstetrics by ten teachers,(19 th edtion ).University of Alberta,Edmonton,Canada . WHO. (2024). https://who.int/news-room/fact-sheets/detail/abortion.com retrieved on the 31st july , 2024.

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