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Abortion 2.pptx

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Abortion 2.pptx

  1. 1. Namus M. Apr 22
  2. 2. Introduction Medical methods Surgical methods Summary References
  3. 3.  Among the 208 million women estimated to become pregnant each year worldwide, 59 percent (or 123 million) experience a planned or intended pregnancy leading to a birth or miscarriage or a still birth.  Surgical methods of abortion  Use of transcervical procedures for terminating pregnancy, including :  vacuum aspiration,  dilatation and curettage (D&C),  dilatation and evacuation (D&E) and  transabdominal procedures (hysterotomy and hysterectomy).  Medication abortion  Use of pharmacological drugs to terminate pregnancy.  Sometimes the term “non-surgical abortion” is also used.
  4. 4.  . MEDICAL TECHNIQUES Intravenous oxytocin Intra-amnionic hyperosmotic fluid - 20% saline - 30% urea Prostaglandins E2, F2?, E1, and analogues - Intra-amnionic injection - Extraovular injection - Vaginal insertion - Parenteral injection - Oral ingestion Antiprogesterones (RU 486 [mifepristone] and epostane) Methotrexate (intramuscular and oral) Various combinations of the above
  5. 5.  . SURGICAL TECHNIQUES Cervical dilatation followed by uterine evacuation - Curettage - Vacuum aspiration (suction curettage) - Dilatation and evacuation (D&E) - Dilatation and extraction (D&X) Menstrual aspiration Laparotomy - Hysterotomy - Hysterectomy
  6. 6.  .
  7. 7.  . MEDICATION ABORTION SURGICAL ABORTION Usually avoids invasive procedure Invasive procedure Usually avoids anesthesia Sedation used if desired Requires two or more visits Usually requires one visit Days to weeks to complete Complete in a predictable period Available during early pregnancy Available during early pregnancy High success rate (~95%) High success rate (99%) Bleeding moderate to heavy for a short time Bleeding commonly perceived as light Requires surveillance to ensure completion of abortion Does not require surveillance in all cases
  8. 8. The first steps in providing abortion care are to: establish that the woman is pregnant estimate the duration of the pregnancy confirm that the pregnancy is intrauterine These are obtained by: History P/E Targeted Investigations
  9. 9.  Past reproductive history  LMP  Breast tenderness/engorgement, nausea & vomiting, fatigue, changes in appetite, and increased frequency of urination  Previous ectopic pregnancy;  any bleeding tendencies or disorders;  history of or presence of STIs;  current use of medications;  known allergies;  Physical or cognitive disabilities/mental illness  Surgical history  History of contraceptive use  Alcohol, tobacco or drug use  Ask for contraindication for medication abortion use  History of sexual violence  Overall Psychological assesment
  10. 10. Vital Signs: Blood pressure, pulse and temperature Confirm pregnancy and estimate its duration by a bimanual pelvic and an abdominal examination Signs of pregnancy include softening of the cervical isthmus and softening and enlargement of the uterus. The uterus is anteverted, retroverted or otherwise positioned Signs of STIs and other reproductive tract infections Health conditions, such as anemia
  11. 11. Laboratory Tests:  Obtaining such tests should not hinder or delay uterine evacuation  Hgb/ Hct  Blood Group & Rh US  Is not routinely required for the provision of abortion  Can help identify an intrauterine pregnancy and exclude an ectopic one  It may also help determine gestational age and diagnose pathologies or non-viability of a pregnancy  Some health-care providers find it helpful before or during
  12. 12. The provision of information is an essential part of good-quality abortion services Adequate relevant information and counseling from a trained health-care professional Information must be provided to each woman, regardless of her age or circumstances, in a way that she can understand, to allow her to make her own decisions about whether to have an abortion and, if so, what method to choose.
  13. 13. Information on abortion procedures what will be done during & after What & for how long is experienced pain management available risks and complications of the method When to resume her normal activities Follow-up care
  14. 14. If a choice of abortion methods is available, clear information about which methods are appropriate and the advantages and disadvantages of each available method.
  15. 15. Contraceptive information and services Is an essential part of abortion care GOAL: to begin the chosen method immediately following abortion This will increase the likelihood that she will continue its correct and consistent use Every woman should be informed that ovulation can return as early as 2 weeks after abortion
  16. 16. A 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 provider is accurate. Signature ________________________________ Date _____________________________________
  17. 17. The most appropriate methods of abortion differ by the duration of pregnancy . The methods summarized are indicative rather than prescriptive with regard to the time limits
  18. 18. A
  19. 19. Have been proved to be safe, effective & feasible The most effective regimens rely on the anti- progestogen, mifepristone. Treatment regimens entail an initial dose of mifepristone followed by administration of a synthetic prostaglandin analogue Gemeprost is similar to misoprostol, but it is more expensive, requires refrigeration, and may only be administered vaginally.
  20. 20. Up to 7 weeks* Mifepristone 200 mg Oral Wait 24-48 hours 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
  21. 21. 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
  22. 22. >12 weeks (63 -84 days) Mifepristone 200 mg Oral Wait 36-48 hours 400 μg oral or 800 μg vaginal misoprostol followed 400 μg vaginal or sublingual misoprostol every 3 hours up to a maximum of five doses, administered in a health-care facility.
  23. 23.  200 mg mifepristone administered orally, followed after 36 to 48 hours by:  400 μg oral or 800 μg vaginal misoprostol followed by 400 μg vaginal or sublingual misoprostol every 3 hours up to a maximum of five doses, administered in a health-care facility. For pregnancies of gestational age greater than 24 weeks, the dose of misoprostol should be reduced due to the greater sensitivity of the uterus to prostaglandins, but the lack of clinical studies precludes specific dosing
  24. 24. For pregnancies of gestational age up to 12 weeks (84 days)  effectiveness of misoprostol alone is lower. 75–90% effective in completing abortion 800 μg administered vaginally or sublingually, and repeated at intervals no less than 3 hours but no more than 12 hours for up to three doses For pregnancies of gestational age over 12 weeks (84 days)  although the time to complete abortion is not as short as when it is used in combination with mifepristone The recommended regimen is 400 μg of vaginal or sublingual misoprostol every 3 hours for up to five doses
  25. 25. 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
  26. 26. Decrease rate of continuing pregnancy Decrease time of expulsion Fewer side effect Improve complete abortion rate Lower cost
  27. 27.  Up to 9 completed weeks since LNMP  Mifeprestone PO 200 mg followed 48 hours later by  Misoprostol 800 µg vaginally. Insert misoprostol deep into the vagina or instruct the woman to do so by herself.  After 12 till 24 weeks completed weeks since LMP  Mifeprestone PO 200 mg followed 48 hours later by  Misoprostol 400µg of oral misoprostol every 3 hours up to a maximum of 5 doses if abortion does not occur.  After 24 till 28 weeks completed weeks since LMP  Mifeprestone PO 200 mg followed 48 hours later by  Misoprostol 100µg of oral misoprostol every 3 hours up to a maximum of 5 doses if abortion does not occur.
  28. 28. A
  29. 29. It is defined as the presence of gestational cardiac activity on vaginal ultrasonography 2 weeks after the initiation of mifepristone  a retained sac 2 weeks after the administration of mifepristone
  30. 30. Absence of pregnancy symptoms History of bleeding, clots, cramps Absence of signs of infection Cervix: closed, not tender Uterus: involutes, firm, not tender Ultrasound: no growth/ viability
  31. 31. Excessive bleeding  Soaking more than 2 thick pads/ hour for 2 consecutive hours  Symptoms of anaemia or hypovolemia Persistent fever:  38˚C or higher or  beginning more than 8 hours after taking misoprostol No bleeding within 24 hours of taking misoprostol Women with these warning signs should call or visit the clinic.
  32. 32. Pre-Procedure Care: The first steps in providing abortion care are to establish that the woman is pregnant and, if she is, to estimate the duration of the pregnancy. Information & Counseling Informed Consent Cervical Preparations Pain Manageement
  33. 33. The following groups of women need cervical preparation regimens: Nulliparous women and those aged 18 or below with gestational duration of more than nine weeks All pregnant women at gestations more than 12 weeks Cervical anomalies or previous surgery
  34. 34. Uses include:  To make abortion procedure quicker and easier to perform by reducing the need for mechanical cervical dilatation. To facilitate the procedure for inexperienced providers.
  35. 35. Methods: Osmotic (hygroscopic) dilators These devices, draw water from cervical tissues and expand, gradually dilating the cervix Requires at least 4 hours to be effective  Pharmacologic Agents Misoprostol 400 micrograms (µg) vaginally or orally three to four hours before the procedure; or  Mifepristone200 milligrams(mg) orally 36 hours before
  36. 36. .
  37. 37. Sources of pain Psychological pain: anxiety, fear, apprehension Cervical pain due to dilatation Uterine cramping due to manipulation
  38. 38. Non-Pharmacological Methods for Relieving Psychological Pain - Gentle, respectful interaction and communication - Verbal support and reassurance - Gentle, smooth operative technique - These supplement but do not substitute for drugs  Pharmacological Means of Addressing Psychological Pain - Anxiolytics/sedatives: relieve anxiety - Analgesics: relieve pain - General anesthesia: for extreme cases
  39. 39. A
  40. 40. It is a method by which the contents of the uterus are evacuated through a plastic or metal cannula that is attached to a vacuum source. Extremely effective (98 – 100 % of cases, at 12 weeks or less) and very safe. A. Manual Vacuum Aspiration (MVA) B. Electric Vacuum Aspiration (EVA) Specific safety benefits compared to sharp curettage include - reduced risk of infection - reduced risk of cervical injury or uterine perforation - reduced amount of cervical dilatation required - decreased blood loss - shortened hospital stay and reduced need for
  41. 41. . MVA Inexpensive Small Portable Quiet Specimen likely to be intact May require repeated reloading of suction EVA More costly but longer life Bulky Less portable Noisy Fragmentation of specimen possible Constant suction
  42. 42. It consists of manual vacuum source (aspirator) that produces suction and holds tissues and blood removed in uterine evacuation procedures. Cannulae are attached to the aspirator to apply suction and aspirate tissue from the
  43. 43. A
  44. 44. Intended for uterine aspiration or evacuation Treatment of incomplete abortion uterine size to 12 weeks LMP First-trimester abortion (menstrual regulation) Endometrial biopsy  Only contraindication: endometrial biopsy in cases of suspected pregnancy
  45. 45.  1. Prepare instruments  2. Prepare the woman  3. Perform cervical antiseptic preparation  4. Administer paracervical block  5. Dilate cervix  6. Insert cannula  7. Suction uterine contents  8. Inspect tissue  9. Perform any concurrent procedures  10. Process instruments
  46. 46. Disassembling the Aspirator Assembling the MVA Creating Vacuum (Charging) Checking Vacuum Retention Selection of Cannulae
  47. 47. Ensure pain medication is given at appropriate time - Ask the woman to empty her bladder - Put the patient in lithotomy position - Ask for her permission to start - Put on barriers and wash hands - Perform a bimanual exam
  48. 48. Follow No-Touch Technique  Use antiseptic sponges to clean cervix and os and then, if desired, vaginal walls Do not retrace areas previously cleaned
  49. 49. Recommended to administer when mechanical dilatation is required Usually 15 – 20 ml of 0.5 to 1 percent lidocaine solution (< 200 mg)
  50. 50. To allow a cannula approximate to the uterine size - Required in most but not all cases - Cannula should fit snuggly in os to hold vacuum - Use gentle operative technique - Use progressively larger series of cannulae - Can use mechanical dilators, laminaria, misoprostol
  51. 51. Gently apply traction to the cervix Rotate the cannula while gently applying pressure Insert cannula slowly until it touches the fundus, draw back Alternatively, insert just past internal os
  52. 52.  Attach charged aspirator Release buttons to start suction Gently rotate cannula 180 degrees in each direction Use “in and out” motion Do not withdraw cannula opening beyond external os
  53. 53. Gritty sensation Frothy – bright red blood No further conceptus material aspirated Uterus contracts as felt by movement of cannula Woman complaining of cramping or pain
  54. 54. Empty contents of aspirator into container Look for POC: villi and decidua should be visible Amnion & chorion are filmy and transparent; Decidua is translucent.
  55. 55. Empty contents of aspirator into container Look for POC: villi and decidua should be visible Amnion & chorion are filmy and transparent; Decidua is translucent.
  56. 56. Such as IUD insertion or cervical tear repair
  57. 57. Proper handling and cleaning of the instrument used and to make ready for the next procedure.
  58. 58.  Vagal Reaction Incomplete evacuation Uterine or cervical injury or perforation Pelvic infection acute hematometra
  59. 59. Physical monitoring Pain management Provision of antibiotics Other health issues Emotional monitoring and support Contraceptive counseling Follow-up care scheduled Discharge instructions given
  60. 60. Performed first by dilating the cervix & evacuating the product of conception - Mechanically scraping out of the contents (sharp curettage) - Vacuum aspiration (suction curettage) - Both Before 14 weeks, D&C or vacuum aspiration should be performed After 16 weeks, dilatation & evacuation (D&E) is performed - Wide cervical dilatation
  61. 61.  D&E is the generic term for suction curettage abortions at >13 wks' gestation.  D&E differs from suction curettage in two principal ways: 1.D&E requires wider cervical dilation, and 2.Physicians need forceps to evacuate more advanced pregnancies.  It is the most common technique used for second-trimester pregnancy termination.  The proportion of abortions performed by curettage techniques is inversely related to GA.
  62. 62.  Uterine perforation Cervical laceration Uterine bleeding due to large fetus and placenta
  63. 63.  Similar to Dilatation & Evacuation.  Evacuation the intracranial content after the delivery of fetal body  Minimize uterine and cervical injury.  Anti microbial prophylaxis recommended  Generally performed for gestations of 24 weeks or later.
  64. 64.  Aspiration of endometrial cavity using a flexible cannula and syringe within 1-3 weeks after failure to menstruate  Several points at early stage of gestation  Woman not being pregnant  Implanted zygote may be missed by the curette  Failure to recognize an ectopic pregnancy  Infrequently, a uterus can be perforated
  65. 65. Abdominal hysterotomy or hysterectomy  Indications Significant uterine disease Failure of medical induction during the 2nd trimester
  66. 66.  .

Editor's Notes

  • Gritty sensation - Frothy – bright red blood - No further conceptus material aspirated - Uterus contracts as felt by movement of cannula - Woman complaining of cramping or pain