Abortion ppt

1. Comprehensive Abortion Care
By Dr. Addisu Tezera
Obstetric and Gynecology Resident
AAU
1

2. Definition
 The term abortion derived from latin word ‘aboriri’
which means to miscarry
 CDC/WHO- pregnancy termination before 20
weeks’ gestation or with a fetus born weighing<
500 g.
 These criteria contradictory because the mean
birth weight of a 20-week fetus is 320g whereas
500 g is the mean for 22 to 23 weeks.
2

3.  Further confusion may derive from criteria set by
state laws that define abortion even more widely.
 Ethiopia .. Abortion defined as termination of
pregnancy before fetal viability, which is
conventionally taken to be less than 28weeks from
LNMP.
 If LNMP is unknown birth weight less 1000gm
taken as an abortion.
 Viability: is a line separating preterm birth and
abortion
 Defined by pregnancy duration and fetal birth
weight for statistical and legal purpose.

3

4.  Biochemical pregnancy defined as pregnancies
with a βhCG level between 10 and 1000 IU/L in a
cycle in which no hCG was administered, no
gestational sac was demonstrated on ultrasound,
and menstruation delayed by no more than 1
week.
 All biochemical pregnancies are by definition,
pregnancies of unknown location, therefore some
biochemical pregnancies can be ectopic
gestations.
4

5.  50-70% of human conception lost before 1st TM
or during 1st month
 Most before implantation
 Wicox (1998) study 221 womens through 707
menstrual cycle
 31% of pregnancy lost after
implantation(judged by hCG)
 2/3 losses are clinically silent
5

6.  Frequency and timing of pregnancy loss
 Implantation by 6 day but not clinically
recognized until 5- 6 weeks
 After clinical recognition 10-15% are lost
 Pregnancy loss is much lower as gestational
age advance
 More than 80 percent of spontaneous abortions
occur within the first 12weeks.
 Only 3% lost after 8wks and <1% at 16wk
6

7. 0
7

8. FIRST-TRIMESTER SPONTANEOUS ABORTION
 Pathogenesis and Risk factor
 With first-trimester losses, death of the embryo
nearly always precedes spontaneous expulsion.
 Death is usually accompanied by hemorrhage
into the decidua basalis.
 This is followed by adjacent tissue necrosis that
stimulates uterine contractions and expulsion.
 In contrast, in later pregnancy losses, the fetus
usually does not die before expulsion, and thus
other explanations are sought.
8

9. Risk Factor
 Defective placentation
 In about two thirds of early pregnancy failures,
anatomic evidence of defective placentation is
apparent.
 During the first trimester, development takes
place in a low oxygen environment supported
by nutrition from the endometrial glands.
 The gestational sac is designed to minimize the
flux of oxygen (O2) from maternal blood to the
fetal circulation.
9

10.  Chromosomal abnormality
 The most common cause of early pregnancy
loss
 50% of clinically recognized pregnancy losses.
 Highest after 45yrs age
 Third decade of age 25%
 Fourth decade of age 50%
 Almost all chromosomally abnormal conceptions
spontaneously abort and over 90% of
conceptions having a normal karyotype
continue.
 ‘Miscarriage may be viewed as a natural 10

11.  Of these, 95% of chromosomal
abnormalities are caused by maternal
gametogenesis errors, and 5% by paternal
errors.
 Risk of abnormality decrease as gestational age
advance
 Occur in 1/3 of 2nd TM spontaneous abortion
and 5% of 3rd TM still birth
 With first-trimester miscarriages, autosomal
trisomy is the most frequently identified
chromosomal anomaly.
 50% of cytogenetically abnormal
spontaneous abortion.
11

12. 12

13. 13

14.  Maternal age
 Many women delay childbearing for social and
professional reasons.
 ‘Maternal age at conception is a strong and
independent risk factor for miscarriage,
irrespective of previous pregnancy outcome.’
 The rate of increase in risk escalates sharply
after 35 years of age, and the chance of a
successful pregnancy in women aged 40 years
or more is poor.
 Advancing maternal age is associated with a
higher rate of pregnancy loss of both normal &
abnormal conceptuses. 14

15.  This secondary to poor oocyte quality in this
age group –
 An increase in chromosomally ‘abnormal
conceptions
 Decline in uterine and ovarian function.
 Several lines of evidence suggest that age-
related instability or degradation of the cellular
mechanisms that govern meiotic spindle
formation and function results in an increasing
incidence of meiotic segregation errors and a
rapid rise in the numbers of aneuploid oocytes
during the later reproductive years.

15

16. 16

17.  Advanced paternal age –
 Has also been identified as a risk factor for
miscarriage.
 The sperm of men whose partners have a
history of unexplained recurrent pregnancy loss
exhibit a higher prevalence of abnormal
morphology, chromosome aneuploidy, and DNA
fragmentation.
 The incidence of sperm aneuploidy rises with
paternal age, if only slightly, and the incidence
of miscarriage in young women with older male
partners is higher than in those whose partners
are young.
17

18.  Prior pregnancy loss
 Prior pregnancy loss also increases loss rates,
but far less than once believed.
 Miscarriage risk increases with the number of
pregnancy losses, but very gradually.’
 After one loss, the risk of another is increased
but does not exceed 30% to 40% even for
women with three loss.
 Overall, the risk is still less than 40% after 4
previous losses and no higher than 50% even
with 6 or more
 No scientific evidence suggests that women
with three losses are etiologically distinct from
18

19. 19

20.  Endocrine factor
 Luteal phase defect
 Polycystic ovary syndrome
 Diabetes mellitus
 Thyroid disease
20

21. 21

22.  Anatomic factor
 Intrauterine adhesions
 Leiomyoma
 Endometriosis
 Mullerian fusion defect
 Cervical insufficiency
22

23. 23

24.  Infection
 Infections are a known cause of late fetal
losses and a logical cause of early fetal losses.
 Microorganisms associated with spontaneous
abortion include variola,
Salmonella typhi, Campylobacter fetus, malaria,
cytomegalovirus, Brucella, Toxoplasma gondii,
Mycoplasma hominis, Chlamydia trachomatis,
and Ureaplasma urealyticum.
24

25.  The proposed mechanisms for infectious
causes of pregnancy loss include:
 (1) Direct infection of the uterus, fetus,
or placenta,
 (2) Placental insufficiency,
 (3) Chronic endometritis
 (4) Amnionitis, or
25

26.  Immunologic factor
 Autoimmune theory—immunity directed against
self, and the alloimmune
theory—immunity against another person.
 Since the mechanisms that allow a mother to
tolerate semi-allogeneic conceptus are not well
defined, it is difficult to assess the role of
aberrant immunologic factors in reproductive
failure.
26

27.  Antiphospholipid syndrome
 The antiphospholipid antibody syndrome (APS)
is defined by these antibodies found together
with various forms of reproductive losses along
with substantively increased
risks for venous thromboembolism ( ACOG,
2011).
 Several autoimmune diseases have been linked
to poor obstetric outcome, but APS is the only
immune condition in which pregnancy loss is a
diagnostic criteria for the disease.
 APS is autoimmune disease with the presence
of antiphospholipid autoantibodies (aPL)
27

28.  The mechanisms by which APS results in RPL
are incompletely understood.
 aPL have multiple potential mechanism of
action, including immune modulation and
endothelial dysfunction.
 This results in an increased risk of pregnancy
loss due to anti-trophoblastic effects & decidual
thrombosis.
28

29.  Antiphospholipid syndrome encompasses
 lupus anticoagulant (LAC) antibodies,
 anticardiolipin (aCL) antibody,
 or anti–β2-glycoprotein.
 ACOG – three or more losses before the tenth
week of pregnancy is considered to fulfill
diagnostic criteria for antiphospholipid
syndrome for prophylactic heparin therapy
 Associations between recurrent fetal losses
earlier than 13 weeks for thrombophilia related
to factor V Leiden, activated protein-C
resistance, prothrombin, and protein-S
deficiency noted.
29

30.  Exogenous agent
 Alcohol
 Caffeine
 Contraceptive
 Cigarette smoking
 Chemicals and radiation exposure
 Drugs
 Trauma
30

31. Classification
 Spontaneous or Induced
 Safe or unsafe
31

32.  Clinical classification of spontaneous abortion
 Threatened abortion
 Inevitable abortion
 Incomplete abortion
 Complete abortion
 Missed abortion
 Septic abortion
 Recurrent abortion
32

33.  Threatened abortion
 Vaginal bleeding through closed cervix during
first 20wks(28wks in Ethiopia)
 Abdominal pain may follow hours to days
 Bleeding the most predictive for pregnancy
loss.
 Over all, approximately half will abort, but this
risk is substantially less if there is fetal cardiac
activity
33

34.  90-96% of threatened abortion with cardiac
activity at gestational age 7-11wks will not
abort.
 Even if miscarriage does not follow early
bleeding, the risk for later adverse pregnancy
outcomes is increased.
34

35.  The prognosis worse with heavy bleeding and if
extended to 2nd TM
 Ectopic pregnancy should be promptly ruled
out.
 ACOG-2011 – diagnosis of IUP should made
cautiously if yolk sac is not seen
 Intrauterine fluid collection may appear
similar to gestational sac= pseudo sac
35

36.  Viability of intra uterine pregnancy should also
ascertained
 Serum progesterone < 5ng/ml suggest dying
pregnancy.
 Serum progesterone >20ng/ml suggest
healthy pregnancy.
 With a robust uterine pregnancy, serum β-
hCG levels should increase at least 53 to 66
percent every 48hours.
36

37.  To avoid interruption of alive IUP at Park land
hospital fetal death diagnosed if
 Anembryonic gestation is diagnosed
when the mean gestational sac diameter
measures ≥ 20 mm and no embryo is seen.
 Embryonic death is also diagnosed if an
embryo measuring ≥ 10 mm has no cardiac
activity.
37

38.  Management
 Analgesia
 Observation with bed rest
 Evacuation
 Heavy bleeding
 Anti –D immunoglobulin(50IU)
 ACOG-2013 Immunoglobulin prophylaxis
controversial because of sparse evidence
based data.
38

39.  Inevitable abortion
 Vaginal bleeding, painful uterine contraction
with open cervix before 20wks
 Rupture of membrane with uterine contraction.
 Management
 If adequate amniotic fluid remained after
ROM women may observed for 48hr with
decreased activity.
 No fever, no bleeding or no abdominal
cramp women resume activity with pelvic
rest
 With fever, bleeding or/and camping…
evacuation.
39

40.  Incomplete abortion
 Vaginal bleeding that follow complete or partial
placental separation with cervical dilation.
 On examination the cervical os is open,
gestational tissue may be observed in the
vagina/cervix.
 Before 10 weeks, they are frequently expelled
together, but later, they deliver separately.
 Severe bleeding may lead to shock, MOF and
DIC
40

41.  Ultrasonographic diagnosis of an incomplete
miscarriage or retained products of
conception(RPC) is problematic.
 Measurement of endometrial thickness and the
appearance of the midline echo have been used
to make these diagnoses, but there is no
agreement on the appropriate cut-off for
endometrial thickness (15 mm is commonly
used) and no threshold has been proven to be
reliable
41

42.  Doppler ultrasound can be helpful in distinguishing
between retained products of conception and
blood clot.
 If blood flow to retained placental tissue is
visualized, then it is possible to make the
diagnosis of retained products of conception.
 However, if blood flow is absent, then either
devascularized retained products of conception
or blood clot.
42

43.  Management
 Expectant … stable patient, no massive /
persistent bleeding
 Medical
 Surgical
43

44.  Complete abortion
 Complete passage of conceptus tissue.
 Uterus small, well contracted and cervix is
closed.
 If an expelled complete gestational sac is not
identified, sonography is performed to
differentiate a complete abortion from
threatened abortion or ectopic pregnancy.
44

45.  Characteristic findings - minimally thickened
endometrium without a gestational sac.
 However, this does not always indicate IUP.
 152 women with heavy bleeding, an empty
uterus with endometrial thickness < 15 mm,
and a diagnosis of complete miscarriage, Six
percent have an ectopic pregnancy.
45

46.  Unless products of conception seen or unless
sonography documents at first an IUP and then
later an empty cavity, a complete abortion
cannot be surely diagnosed.
46

47.  Missed abortion
 Historically this term used to define retained
died product of conception with closed cervix
 Fetal viability ceases weeks before maternal
symptoms of pregnancy loss.
 Almost all losses are retained some time before
clinical recognition means that virtually all
losses could be considered “missed abortions,”
thus this once widely used term is actually
archaic.
 Mean duration of death to spontaneous
abortion is approximately 6wks. 47

48.  Septic abortion
 Any of spontaneous abortion or induced
abortion complicated by infection.
 Horrific infections and maternal deaths
associated with criminal septic abortions have
become rare with legalized abortion.
 May occur in 1-2% of incomplete / threated
abortion
48

49.  Bacteria gain uterine entry and colonize dead
conception products.
 Organisms may invade myometrial tissues and
extend to cause parametritis, peritonitis,
septicemia, and rarely endocarditis.
 Severe necrotizing infections and toxic shock
syndrome caused by group A streptococcus is
life threatening.
49

50.  Infection by Clostridium perfringens and
Clostridium sordelli may cause TSS, but rare.
 Infection is usually due to Staphylococcus
aureus, Gram negative bacilli, or some Gram
positive cocci.
 Mixed infections, anaerobic organisms, and
fungi, can also be encountered.
50

51.  Common clinical features fever, chills, malaise,
abdominal pain, vaginal bleeding, and
discharge.
 Physical examination may reveal tachycardia,
tachypnea, lower abdominal tenderness, and a
boggy, tender uterus with dilated cervix.
 Women may be afebrile with severe endothelial
injury, capillary leakage, hemoconcentration,
hypotension, and a profound leukocytosis.
51

52.  Few women may develop – AKI, ARDS, or DIC
 To prevent postabortal sepsis, prophylactic
antibiotics are given at the time of induced
abortion or spontaneous abortion that requires
medical or surgical intervention.
 ACOG-2011- recommends doxycycline, 100 mg
orally 1 hr before and then 200 mg orally after
a surgical evacuation
52

53.  Management
 Broad antibiotics
 Evacuation RPC
53

54. Pre-abortion care
Determine
gestational age
Routine use of antibiotics
with surgical abortion
Provide information for decision-
making and voluntary consent
54

55. Clinical recommendations
Women should have a choice of
abortion method
Medical
Surgical
55

56. Surgical methods
56

57. Surgical Methods
Up to 12 to 14 weeks
Manual vacuum
aspiration (MVA)
Replace
D&C (sharp curettage)
with MVA or EVA
Electric vacuum
aspiration (EVA)
57

58. Surgical Methods
After 12 to 14 weeks
Dilatation and evacuation
(D&E)
Replace
D&C (sharp curettage)
with D&E
58

59. Surgical Cont.……
 Dilatation and Curettage (D&C)
 Transcervical approaches to surgical abortion
require first dilating the cervix and then
evacuating the pregnancy by mechanically
scraping out the contents—sharp curettage, by
suctioning out the contents—suction curettage,
or both. Vacuum aspiration, the most common
form of suction curettage
59

60. Surgical Cont.………..
 Hygroscopic Dilators
 Trauma from mechanical dilatation can be
minimized by using devices that slowly dilate
the cervix . These devices, called hygroscopic
dilators, draws water from the cervical tissues ,
expand and gradually dilate the cervix.
60

61. Hygroscopic…….
61

62. Hygroscopic………
62

63. Surgical Cont.……
 Technique for Dilatation and Curettage
63

64. Cont.……
64

65. Contd.……
65

66. A sharp curette
A sharp curette is advanced into the
uterine cavity
while the instrument is held with the
thumb and forefinger as
shown in Figure 18-9. In the
movement of the curette, only the
strength of these two fingers should
be used. (From Word, 2012,
66

67. • Provide pre- or peri-operatively
• If not available, the abortion
can still be performed
Routine use of antibiotics
with surgical abortion
67

68. Clinical recommendations
Women should have a choice of
abortion method
Surgical
Medical
68

69. Medical Abortion
 Throughout history, many naturally occurring
substances have been tried as
abortifacients
 Became an alternative method of abortion with the
availability of prostaglandin analogs in the early
1970s and the antiprogestogen mifepristone in the
1980s
 The ant progestin mifepristone; the ant metabolite
methotrexate; and the prostaglandin misoprostol.
69

70. Medical……..
Mifepristone
 Mifepristone (RU-486), an antiprogestin, is
indicated for medical termination of pregnancies
up to 49 days of gestation.
 Used for cervical ripening in both 1st and 2nd TMA
and for induction of Labor after IUFD.
 Used alone and prior to 6 weeks gestation, 85%
effective to result in complete abortion.
70

71. 71

72. Medical…….
 Misoprostol
is a prostaglandin E1 analogue that has been approved
by the FDA to be taken orally for the prevention and
treatment of gastric ulcers associated with the use of
NSAID.
Become an important drug in obstetrical and gynecologic
practice b/c of its uterotonic and cervical ripening actions.
Used for elective medical abortion, cervical ripening
before surgical abortion, evacuation of the uterus in cases
of embryonic or fetal death, uterine evacuation in
incomplete abortion, and induction of labor.
In 2000 , ACGO recommended use of misoprostol
as safe and efficient
72

73. World map of misoprostol approval
(source: www.gynuity.org
73

74. Medical……
 Pharmacokinetics
Rapidly absorbed from the GI tract, converted to its
pharmacologically active metabolite,
Misoprostol acid……peak….30min.
Primarily metabolized in the liver and less than 1% of its
AM is excreted in urine.
The dose should be reduced for women with hepatic
disease.
Vaginal application results in slower but prolonged overall
exposure to the drug than oral misoprostol.
74

75. 75

76. Medical……
 Mechanism of action
Oral or vaginal administration of Misoprostol during
pregnancy……… results in cervical dilatation, uterine
contraction, uterine bleeding and often depending on the
dose and duration of pregnancy, complete abortion.
Side effects: Uncommon 80-90%, of women tolerate
misoprostol well
However, cramping, nausea, vomiting, diarrhea and
fever are reported.
All of these side effects are dose dependent and
reversible.
Success rate …..5 – 97 %( Blanchard 2002)
76

77. Research
 Congenital defect ( Gonzalez 1998)
Congenital facial paralysis and limb defect reported
 Prospective study ( pastuszak 1998)
Two arm study 86 pregnant women ……..no
difference
 WHO recommendations.
77

78. Mechanism
78

79. Medical Abortion up to 9 weeks
Mifepristone & Misoprostol
Up to 7 weeks* Mifepristone
200 mg Oral
Wait 24-48
hours
Or 36 -48 hrs
Misoprostol 800
mcg Vaginal OR
Buccal OR
Sublingual
Misoprostol 400
mcg Oral
7-9 weeks* Mifepristone
200 mg Oral
Wait 24-48
hours
Misoprostol 800
mcg Vaginal OR
Buccal OR
Sublingual
79

80. 9 -12 weeks
(63 -84 days)
Mifepristone
200 mg Oral
Wait 36-48
hours
Misoprostol
800 mcg
Vaginal
Additional
Misoprostol 400
mcg Vaginal or
Sublingual
every 3 hours
for maximum of
4 further doses
Medical Abortion 9-12 weeks
Mifepristone & misoprostol
In a health
facility
80

81. Greater
than12
weeks
(more than
84 days)
Mifepristone
200 mg Oral
Wait 36-48
hours
Misoprostol
400 mcg Oral
OR
800 mcg
Vaginal
Additional
Misoprostol 400
mcg Vaginal or
Sublingual every
3 hours for
maximum of 4
further doses
Medical Abortion
over 12 weeks up to 24 weeks
Mifepristone & misoprostol
In a health
facility
81

82. Second trimester
Between 13 – 26 week
 Misoprostol 600mcg vaginal followed by 400mcg
every 4 hours up to 5 doses
 Use 200mcg in case of prior scar ( 13-17wk.)
 Use 100mcg in prior scar ( 18-26 wk.)
82

83. Clinical recommendations
Medical Abortion
Mifepristone followed by
misoprostol
Misoprostol alone when
mifepristone is unavailable
83

84. Up to 12
weeks
(up to 84 days)
Misoprostol 800
mcg
Vaginal or
Sublingual
REPEAT
Misoprostol
every 3-12 hours
for up to 3
doses until
expulsion
Return for
confirmation of
completed
abortion in 7-
14 days
Medical Abortion up to 12 weeks
Misoprostol Alone
84

85. Medical Abortion
Misoprostol for incomplete abortion
Misoprostol for
incomplete abortion
Single dose:
Misoprostol 600 mcg
orally
Single dose:
Misoprostol 400 mcg
sublingually
85

86. Missed abortion
 800 mcg vaginal stat , or
 600mcg sublingual stat
 80- 90 % effective
86

87. High dose Oxytocin
 Given as a single agent in high doses, oxytocin will
effect second-trimester abortion in 80 to 90 percent
of cases.
87

88. Combination of medication abortion regimens
 Combination of medication abortion regimens ;
combination of two drugs is more effective than
any of the two
 Mifepristone + Misoprostol has proven to be the
most successful and affordable medical
abortion regimen. 92-98% of women ≤ 9 weeks.
 90% of women expel the conceptus material
completely within 6 hours of administration
of misoprostol( WHO 2003)
 Methotrexate + Misoprostol…….. 88%-100 %
88

89. Research evidence ( miso vs. MVA)
 “Comparison of Miso with MVA for treatment of
incomplete abortion”
 270 women randomized for 600mcg miso and MVA
 Success was 100% for MVA and 91% for miso
 Women with MVA reported less side effect but
more pain
 Women with miso were more satisfied
89

90. Absolute contraindications
 Ectopic pregnancy , GTD
 High risk of uterine rupture
 Intrauterine device
 Allergy to prostaglandins
 Contraindications to medical or surgical uterine
evacuations (eg, hemodynamically unstable,
coagulopathy)
90

91. MVA……..
 Steps of the MVA Procedure
1. Prepare instruments
2. Prepare the woman
3. Perform cervical antiseptic prep
4. Administer par cervical block
5. Dilate cervix
6. Insert cannula
7. Suction uterine contents
8. Inspect tissue
9. Perform any
concurrent procedures
7. Process instruments
91

92. 92

93. Steps……..
 Step 1: Prepare Instruments
 Check vacuum retention of aspirator
 Have more than one aspirator available
Uterine size 4–6 weeks LMP: suggest
4–7mm canula
Uterine size 7–9 weeks LMP: suggest
5–10mm canula
Uterine size 9–12 weeks LMP: suggest
8–12mm canula
93

94. Step 2: Prepare the Woman
 Ensure pain medication is
given at appropriate time
 Ask the woman to empty
her bladder
 Help her onto the table
 Ask for her permission to
start
 Put on barriers and wash
hands
 Perform a bimanual exam
94

95. Consent Form for Uterine Evacuation
After having consulted with my health service provider about my
health condition, I, (name of client) , hereby
consent to a procedure for safe termination of pregnancy. I have
been counseled and informed about the alternative methods and
about the possible side effects and outcomes of the procedure.
In the event of complications arising during the procedure, I
request and authorize the responsible health service provider to
do whatever is necessary to protect my health and wellbeing.
I confirm that the information that I provided to my health service
95

96. Step 3: Perform Cervical Antiseptic Prep
96

97. Step 4: Administer Paracervical Block
97

98. Step 5: Dilate Cervix
 Required in some but not all cases
 Cannula should fit snugly in os to hold vacuum
 Use gentle operative technique
 Use progressively larger series of cannulae or
mechanical dilators
 Can use misoprostol
98

99. Step 6: Insert Cannula
99

100. Step 7: Suction Uterine Contents
 Use “in and out” motion and 180* rotation
 Do not withdraw cannula opening beyond external
os
 When finished
 Push buttons down and forward to close valve
 Disconnect cannula from aspirator OR
 Remove cannula from uterus without
disconnecting
100

101. Signs That the Uterus is Empty
 Red or pink foam without tissue passing through
cannula
 Gritty sensation over surface of uterus
 Uterus contracting around cannula
 Increased uterine cramping
101

102. Step 8: Inspect Tissue
 Empty contents of aspirator into container
 Look for POC: villi and decidua should be visible
102

103. MVA steps….
 Step Nine:
Perform any concurrent procedures
 Step Ten:
Process instruments
103

104. Decrease MVA function If,
 Aspirator is full
 Cannula is withdrawn past os
 Cannula is clogged
 Aspirator is incorrectly assembled
104

105. When Aspirator is Full
1. Close the valve
1. Detach the cannula and leave in os
2. Open the valve and squeeze plunger arms
3. Push plunger and empty the aspirator
4. Establish new vacuum
5. Reattach to the cannula and continue 105

106. When Cannula is withdrawn past Os
1. Remove cannula and aspirator; don’t touch
vaginal walls
2. Detach and empty aspirator
3. Re-establish vacuum
4. Reconnect aspirator to cannula
5. Continue evacuation
106

107. When Cannula is Clogged
 Ease it back toward, not through, external os OR
 Close valve and withdraw cannula out of uterus
 Remove tissue clogging cannula using forceps
 Reinsert cannula and continue aspiration
 Never push tissue through cannula while in uterus
107

108. Loss of vacuum
 Reassemble aspirator
 Check O-ring for damage
108

109. Pharmacological Means of Addressing Psychological
Pain
 Anxiolytics/sedatives: relieve anxiety
 Analgesics: relieve pain
 General anesthesia: for extreme cases
109

110. Managing complications
• Ongoing pregnancy… 3 -
5%
• Incomplete abortion
requiring aspiration …2 -
5%
• Infection…..< 1%
• Hemorrhage requiring
transfusion…. 0.1% -
0.5%
• Uterine perforation
• Anesthesia-related
Risks low when
performed by
trained provider
110

111. Complications………
 Major complications
 Shock
 Severe Vaginal bleeding
 Sepsis
 Intra abdominal injury
111

112. Management of shock
 ABC
 Check v/s frequently
 Open both hand iv line
 Ns /RL …1 ltr per 15-30 min.
 Keep her warm
 Blood transfusion if Hg < 7mg/dl
 Antibiotics iv or im , if needed
 Monitor fluid input/ out put 112

113. Management of severe vaginal bleeding
 Open iv line
 Intravenous fluid to replace lost volume
 Control of bleeding
 Antibiotics
 Tetanus toxoid if exposed
 Pain management
 Stabilization
 Uterine evacuation for incomplete abortion
 Surgery, if needed to arrest bleeding for organ damage
113

114. Management of intra abdominal injury
 Life threatening
 Replacement of blood loss
 Antibiotics therapy
 Uterine evacuation under direct vision( laparatomy)
 Repair or resection of injured tissue
 Control of pain
114

115. Sepsis
 ABC
 Iv fluid replacement
 Control of bleeding
 Antibiotics if needed
 Control of pain
 Blood transfusion if needed
115

116. Comparisons of complication by MVA vs. SMC
Variables MVA(%) SMC(%)
Rate of
incomplete
evacuation
< = 8 weeks 1.6 2.1
9 - 12weeks 1.8 4.2
> 13 weeks 5.9 8.4
Excessive blood
loss
0 – 15.7 o.5 – 28
Pelvic infection 0.2 - 5.4 0.7 – 6
Cervical injury 0.3 – 1 0.3 – 6.4
Uterine
perforation
0 – 0.05 0 – 3.3
116

117. Post Abortion Care (PAC)
As in all patients seeking medical care, the standard
approach to a patient with abortion is to look on the
whole person and social context; not on specific
disease or organ.
 Is a comprehensive approach to providing abortion
services that takes into account the various factors that
influence a woman’s individual health needs both
physical and mental as well as her ability to access
services and her personal circumstances.
117

118. Elements of PAC
 1. Community-service provider partnership
 2. Counseling
 3. Emergency treatment of incomplete abortion
and its complications
 4. FP services
 5. Linkage with other RH service.
118

119. . Community-service provider partnership
 Communities can play a key role in reducing
maternal morbidity and mortality.
 Partner ship b/n health facilities, trained providers
and community leaders and groups
 To understand coexisting problem, barriers to service
and women's perceptions
119

120. Counseling :
 A structural interactions through w/c a person
voluntarily receive emotional support and guidance
 Focuses on individual women's need and
situations.
 Private session in a private room
 Keep confidential
 Informed consent
120

121. Emergency treatment of incomplete abortion and its
complications
 Health providers and health facilities at all levels
are adequately prepared to identify and manage
complication.
121

122. Post abortion Family Planning services
 To avoid repeated unwanted pregnancy and
abortion
 All methods can be used immediately after
uncomplicated abortions
122

123. Linkage with other RH services:-
 Rational and logical
 Same target population
 Sexual and reproductive health problems share many of problems
 To improved access to sexual and reproductive health and abortion service
 Increase uptake of service
 Improve quality of care
 Improve coverage
 To improve abortion related stigma and discrimination
123