Short comprehensive overview of abortion and its management along with the steps of dilatation and evacuation.

1. ABORTIONS
Abortion:
🞂 The Termination of pregnancy either removed or expelled (spontaneous or induced) from the uterus
during 20weeks of gestation or a fetus weighing<500mg when the fetus is not viable.
🞂 An abortion after 20 to 28 weeks of gestation is called as stillbirth.
🞂 A live birth is defined as baby born alive even it dies shortly after.
Types of abortion:
Spontaneous Induced
Threatened Inevitable Incomplete Complete Missed Septic Medical Surgical
SPONTANEOUS ABORTION:
Threatened Abortion: Condition in which the pregnancy is complicated by the vaginal bleeding
before the 20th
week of gestation manifested by slight bleeding per vaginum, usually painless or dull
pain in the lower abdomen,uterus and cervix are soft, cervical opening or os is closed.
Management/treatment:
1. Bed rest for few days until bleeding stops.
2. Relief of pain by suitable pain killers (Tab Buscopan, tab spadix, tab panadol) or Diazepam 5mg BD
3. Injection of Gravibinon (1ml, 2ml) after 6 weeks of gestation or tab Duphastan 10mg is administered.
4. 80% pregnancies survive until term if heart beat is present.
Inevitable Abortion: An abortion in which clinical pregnancy is complicated by vaginal bleeding &

2. cramp likelower abdomen pain; cervix is partially dilated attesting to the inevitability of the abortion.
Management/ treatment:
1. Accelerate the process of expulsion maintain strict asepsis.
2. If pregnancy is less than 12 weeks suction evacuation is done.
3. If greater than 12 weeks expulsion by cytotec tablets or Oxytocin infusion is done.
4. Excessive bleeding is controlled by Inj methergin 0.2 mg, inj transamine (500mg) or IV fluids
or bloodtransfusion may be necessary
Incomplete Abortion: The process of abortion has already taken place, but the entire products if
conception are notexpelled & a part of it left in the uterine cavity manifested by: fleshy mass per vaginum,
continuous pain in lower abdomen, persistent vaginal bleeding, open internal or cervical os.
Management/ treatment:
Evacuation of the retained products of conception by D & c or other appropriate method (tab misoprostol
200ug pervaginum every 4 hours, ovum forceps or blunt curette in late abortions ) acccordig to the
duration of pregnancy or amount of retained products.
Complete abortion: When the products of conception are completely expelled from the uterus. Called
complete miscarriage manifested by fleshy mass per vaginum with relief of abdominal pain & vaginal
bleeding is in trace&cervical os is closed.
Management/ treatment:
Bed rest & wait and watch technique, provide antibiotics or other multivitamins according to case requirements.
Missed Abortion: The fetus is dead and retained in the uterus for the variable period of time. It is
diagnosed when a fetus is with a CRL of 5mm with no fetal heart beat. It is manifested by cervix is closed
with firm internal os, uterus issmaller in size, no fetal heart beat.

3. Management is evacuation of the dead fetus same as in incomplete abortions.
Septic abortions: Any abortion associated with clinical evidences of infection of the uterus and its
contents eitherinfection of the uterus only, its tubes, ovaries or the entire peritoneum, a leading cause of
spontaneous abortions manifested by abdominal pain, fever & may be diarrhea, purulent vaginal
discharge, rising pulse rate, abdominaltenderness, soft cervix with opened internal os.
Management: Broad spectrum antibiotic (metronidazole, ciprofloxacin, Ampicilin) started, or uterus is
evacuated, Ivfluids many need to be administered
INDUCED ABORTIONS
Abortion performed by the women by herself outside the recognized medical system. Most induced
abortions are donein 1st
12 weeks of gestation.
Medical: Tab methotrexate or most commonly used tab cytotec 200ug (misoprostol)
Surgical: It is done by either
1. Suction evacuation: Manual suction evacuation or electric evacuation
2. Dilatation & curettage.

4. Manual Suction evacuation: It is a surgical abortion procedure during which a health care provider
uses gentlesuction to empty uterus. It’s a minor procedure performed under local anesthesia. It is totally
safe with 99% effectiveness.
Equipments for Suction evacuation:
1) Rectangular tray
2) Apron
3) Non sterile gloves
4) Manual evacuation syringe
5) Dilators of different sizes
6) Disposable syringe, cotton, guaze piece,
7) Inj xylocain
8) Lignocain gel
9) Allis forcep
10) Sponge holding forcep
11) Ovum forcep
12) Uterine curette (if needed)
13) Container for products of conception
STEPS FOR SUCTION EVACUATION:
1)
Prepare the patient:
 Administer pain medication before the
procedureto have maximum effect when the
procedure begins.
 Give prophylactic antibiotics to all
women, ortherapeutic antibiotics if
indicated.
 Ask the woman to empty her bladder.
 Conduct a bimanual exam to confirm uterine
sizeand position.
 Insert speculum and observe for signs of
infection,bleeding or incomplete abortion.

5. 2) Perform Cervical Antiseptic Prep:
Use antiseptic-soaked sponge to clean cervical os. Start
at os and spiral outward without retracing areas. Repeat
until os hasbeen completely covered by antiseptic.
3) Perform Paracervical Block
Perform paracervical block with 20cc of 1% lidocaine, or
10ccof 2% lidocaine.
Inject a small amount of lidocaine (1-2cc) into the cervix
at thetenaculum site (12 o’clock).
Inject the remaining lidocaine in equal amounts
at thecervicovaginal junction at 2, 4, 8 and 10
o’clock.
Always aspirate before injecting to prevent intravascular
injection of lidocaine.
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4) Dilate Cervix
• Observe no-touch technique when dilating the
cervix andduring
aspiration. Instruments that enter the uterine cavity should
nottouch
your gloved hands, the patient’s skin, the woman’s
vaginalwalls, or
unsterile parts of the instrument tray before entering the
cervix.
• Use mechanical dilators or progressively larger
cannulae togently dilate the cervix to the right size.
5) Insert Cannula
• While applying traction to the tenaculum, insert
cannulathrough the
cervix, just past the os and into the uterine cavity.
• Do not insert the cannula forcefully.
6) Prepare the Aspirator

6. 7) Suction Uterine Contents:
 Attach the prepared aspirator to the cannula.
 Release the vacuum by pressing both buttons.
 Evacuate the contents of the uterus by gently
and slowly rotating the cannula 180° in each
direction,using an
in-and-out motion.
 When the procedure is finished, depress the
buttonsand disconnect the cannula from the
aspirator. Alternatively, withdraw the cannula
and aspirator without depressing the buttons.
8) Inspect Tissue:
• Empty the contents of the aspirator into a container.
• Strain material, float in water or vinegar and view with a
lightfrom beneath.
• Inspect tissue for products of conception, complete
evacuationand molar pregnancy.
• If inspection is inconclusive, reaspiration or other
evaluationmay be necessary.
9) Perform Any Concurrent Procedures
• When procedure is complete, proceed with
contraception orother
procedures, such as IUD insertion or cervical tear repair.
10) Immediately After the Procedure

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• Reassure the woman that the procedure is finished.
• Ensure she is escorted to the recovery area.
• Immediately process or discard all instruments,
according tolocal
protocols.
SIGNS THAT INDICATE THE UTERUS IS EMPTY:
• Red or pink foam without tissue is seen passing through the cannula.
• A gritty sensation is felt as the cannula passes over the surface of the evacuated uterus.
• The uterus contracts around or grips the cannula.
• The patient complains of cramping or pain, indicating that the uterus is contracting.