Abortion lecture

1. Dr chaltu R

2.  The word abortion derives from the Latin aboriri—to
miscarry.
Abortion: spontaneous or induced termination of
pregnancy before fetal viability.
 Definition differs from countries to countries based on
technology of neonatal care.
 The WHO defines it as expulsion or extraction of an embryo
or fetus weighing 500 g or less from its mother. This typically
corresponds to a gestational age of 20 to 22 weeks or less.
 Ethiopian definition is termination of pregnancy before 28
weeks of gestation or weight less than 1000g.

3.  Can be spontaneous or induced.
 Spontaneous abortion , also known as miscarriage.
 Patients prefer the term "miscarriage" to "abortion."
 Induced abortion is the medical or surgical termination of
pregnancy before the time of fetal viability.
 Can be safe or unsafe.
 Unsafe abortion persons lacking the necessary skills or in an
environment that does not conform to minimal medical standards,
or both.
 Recurrent abortion ≥3 consecutive losses of clinically recognized
pregnancies prior to viability.
 primary and
 secondary recurrent abortion

4.  Therapeutic abortion
 Abortion done for the purpose of saving the life of the
mother or if the fetus has congenital/ chromosomal/
metabolic disorders that is incompatible with life often both.
 Elective abortion
 The interruption of pregnancy before viability at the request
of the woman, but not for medical reasons, is usually
termed elective or voluntary abortion.
 According to the National Vital Statistics Reports,
approximately one pregnancy is electively terminated for
every four live births in the United States.

5.  Spontaneous abortion is the most common complication of
early pregnancy.
 15% of all clinically recognized pregnancies  spontaneous
abortion.
 More than 80% of these occurs in the 1st 12weeks of
pregnancy.
 Another 15% of all pregnancies  unsafe abortion.
 World wide13% of maternal deaths– due to complication
of abortion.
 For every maternal death due to unsafe abortion
—>10-15 women suffer from morbidity.
 In some developing countries also contributes to 50%
maternal deaths.

6.  Hemorrhage into the decidua basalis, followed by necrosis of
tissues adjacent to the bleeding=== ovum detaches==
uterine contractions == expulsion of the fetus

7. Fetal Factors:
1. Chromosomal abnormalities:
 Cause at least 50% of early abortions.
2. Blighted ovum (anembryonic GS): where there is
no visible fetal tissue in the sac. 70% first-
trimester abortion

8. Maternal Factors
1. Maternal infections: uncommon
2. Trauma and maternal surgery :
 External to the abdomen or during abdominal or pelvic
operations.
3. Endocrine causes:
 Progesterone deficiency/LPD
 DM
 Thyroid Disease
 Polycystic Ovarian Syndrome

9. 4. Drugs & environmental causes:
 e.g. tobacco, alcohol, radiation, IUD in place, arsenic, lead,
…
5. Maternal malnutrution: uncommon
6. Immunological causes: SLE , APS, ...
7. Aging sperm or ovum.
8. Psychological conditions & over fatigue.
9. Uterine defect
 Septum, Asherman’s syndrom, Subcutaneous myoma.
 Cervical incompetence
10. Thrombophilias

10.  Clinical Classification of Spontaneous Abortion:
1. Threatened
2. Inevitable
3. Incomplete
4. Missed
5. Complete abortion
6. Septic abortion

11.  Bleeding through a closed cervical os.
 The bleeding is often painless, but may be
accompanied by minimal/mild suprapubic pain.
 On examination the uterine size is appropriate for
gestational age.
 Fetal cardiac activity is detectable by ultrasound if
the gestation is sufficiently advanced.
 The exact etiology of bleeding often cannot be
determined and is frequently attributed to marginal
separation of the placenta.

12.  About two thirds of pregnancies in women with
threatened abortion have a live embryo or fetus
present and
 about 85% will survive.

13.  Imminent abortion.
 Significant bleeding.
 Painful uterine cramps/contractions.
 The cervix is dilated to variable extent.
 The gestational tissue can often be felt or visualized through
the internal cervical os but no passage.
 Amnionic fluid leakage.

14.  After 12 weeks of gestation.
 The membranes often rupture and the fetus is
passed.
 Significant amounts of placental tissue may be
retained.
 On examination the cervical os is open, gestational
tissue may be observed in the vagina/cervix.
 The uterine size is smaller than expected for
gestational age, but not well contracted.

15.  The amount of bleeding varies, but can be severe enough to
cause hypovolemic shock.
 Painful cramps/contractions are often present.

16.  Before 12 weeks of gestation.
 The uterus is small and well contracted with a closed
cervix.
 Scant vaginal bleeding, and only mild cramping.

17.  In-utero death of the embryo or fetus prior to the periods of
viability with no expulsion of placental or fetal tissue.
 Regression of symptoms associated with early pregnancy
(eg, nausea, breast tenderness) and they don't "feel
pregnant" anymore.
 Vaginal bleeding or brown discharge may occur.
 The cervix is usually closed.

18. • May complicate both spontaneous and induced abortion.
• Fever, chills, malaise, abdominal pain, vaginal bleeding, and
foul smelling vaginal discharge.
• Physical examination may reveal
 tachycardia,
 tachypnea,
 lower abdominal tenderness, and
 a boggy, tender uterus with dilated cervix.
The infection may spread, leading to salpingitis, generalized
peritonitis, and septicemia.
Infeetions are usually polymicrobial.

19. Physiologic (ie, believed to be related to
implantation) bleeding
Ectopic pregnancy
GTD
Other Cervical, vaginal, or uterine pathology

20. Initial assessment
• Consider abortion– If at least two of the following are
experienced in a reproductive age: -Vaginal bleeding
-Lower abd. Pain &/or cramp
-Hx of amenorrhea
• Complete clinical assessment is necessary in such patient:
History: ask about:-
 LMP
 Bleeding(duration, amount)
 Cramping(duration, severity)
 Abdominal or shoulder pain
 Symptoms of infection

21.  Physical exam:
V/S
General appearance
General system exam
Abdominal exam( check)
bowel sounds
distension
tenderness-direct
-rebound
Remove any visible products from cervix or vagina!

22.  Note(speculum exam)
Amount of bleeding
Cx- dilatation or laceration
Foul smelling discharge
 Bimanual exam:
-Size and consistency of uterus
-Pelvic mass
-Pelvic tenderness
-Cx- closed or dilated
-Cx- motion tenderness

23. Laboratory
 Hg/Hct, B/G & Rh
 Based on clinical assessment when indicated:-
 CBC
 ESR
 U/A
 RFT, LFT
 Plain film of the abdomen (erect)
 Pelvic U/S
 hCG
 Cx- culture

24. 1)Threatened Abortion
 Bed rest, pelvic rest
 Avoid intercourse & douching
 Monitor progress-V/S,U/S evaluation, Vx bleeding
 If sign of infection—Evacuate Ux after antibiotics
coverage
2)Complete abortion
 Confirm completeness—U/S
3) Incomplete, Inveitable, Missed abortion
 Evacuation of the Ux
4) septic abortion
 Broad spectrum antibiotics & Evacuation of the Ux

25. Method of evacuation
a) Surgical method
 Electric Vacuum Aspiration(EVA)
 Manual Vacuum Aspiration(MVA)
 Dilation and evacuation (D & E)
 Hysterotomy or hysterectomy
b) Medical method
 Prostaglandins(Mifepristone, Misoprostol)
 Oxytocin(High dose)

26. Mifepristone/Misoprostol
 Mifepristone, 200 mg orally followed 24-48 hours by:
 Misoprostol, 400 µg vaginally, buccally, or sublingually
Misoprostol Alone
 800 µg vaginally or sublingually, repeated for up to
three doses
Methotrexate/Mlsoprostol
 Methotrexate, 50 mg/m2 intramuscularly or orally
followed by:
 Misoprostol, 800 µg vaginally in 3-7 days. Repeat if
needed 1 week after methotrexate initially given

27.  Higher complications with unsafe abortion.
Short term
 Hypovolumic shock(h’ggic shock)
 Sepsis
 Septic shock
 Uterine perforation
 Intra-abdominal injury
 Heamatometra
 Cervical injury
 Anesthesia complications
 Death

28. Long term
 Infertility—secondary to infection, hysterectomy & asherman
syndrome
 Tubo-ovarian abscess, hydrosalpinx
 Chronic pelvic pain
 Dyspareunia
 Dysmenorrhea

29. 1) shock
s/s
 Anxious, restless, confused or unconscious
 Tachycardia, or weak pulse
 Tachypnea
 Low blood pressure or unrecordable
 Pallor skin, conj., palms, mouth
 Cold skin, clammy skin
 Oliguria
Causes
 Severe blood loss
 Infection(sepsis)

30. Mx:
Universal measures
• Ensure airway is open
• Turn head & body to the side in case she vomites
• Keep her warm
• Elevate legs
• O2 supplementation
• Fluids: Crystalloids
• Blood transfusion
Hgb< 5mg/100ml/Hct< 15%
• Medicines
If signs of infection- Broad
spectrum antibiotics

31. 2) Uterine perforation
S/S
 An instrument( sound, cannula, curette) extends beyond
expected limit
 Fat or bowel is found in the tissue removed from the Ux
 Severe pain
 Unstable V/s
 Hypotension in the absence of external bleeding
Mx:
 Stabilize the pt
 Monitor V/S —If unstable(hypotension)
 Immediate Laparatomy
 Broad spectrum antibiotics

32. 3) Sepsis
 Etiology—Polymicrobial
 Symptoms
-Chills, fever, sweating
-Hx of interference
 Signs
-Foul smelling vaginal discharge
-Distended abd.
-Tenderness
-Low B/P
Mx:
 If in shock—mx as above
 Broad spectrum antibiotics

33. 4) Intra-abdominal injury
Symptoms
 Nausea, vomiting
 Shoulder pain
 Fever
 Abdominal cramp & pain
Signs
 Distended abd.
 Decreased bowel sound
 Tense hard abdomen
 Rebound tenderness
Mx:
 Resuscitation(as above)
 I.V. antibiotics
 Laparatomy-Rx-accordingly…!!!!!

34.  Consists of series of medical and related
interventions designed to manage the
complications of spontaneous and induced
abortion, both safe and unsafe, and address a woman’s
related health care needs.
 Aim of PAC:
-Reduce maternal morbidity and mortality
-Improve women’s sexual and reproductive health
and lives
 Ovulation may resume as early as 2 weeks after an
early pregnancy loss.

35.  PAC consists of five elements:
1) Treatment-of unsafe and incomplete abortion and abortion
related complications that are potentially life threatening.
2) Counseling-to identify and respond to women’s emotional
and physical health needs and other concerns.
3) Contraceptive and family planning services-to help women
prevent unwanted pregnancy or practice birth spacing.

36. 4)Reproductive and other health services
-Testing and treating of STI, including HIV/AIDS and
reproductive tract infection
-Preconception care if women wants to become
pregnant
-Infertility screening and treatment
-Screening and counseling for women who experienced
violence
-Counseling for nutritional needs
-Cancer screening-cervical
-ovarian
-endometrial

37. 5)Community and service provider partnership
-to prevent unwanted pregnancy and unsafe abortion
-mobilize resources to help women receive appropriate
and timely care for abortion and its complications.