1. Abortion complications pptptepff abortion complications

07/06/2025 Dr 1
Abortion
ABORTION

07/06/2025 Dr 2
Definitions of terms
• Abortion: is the process of termination or expulsion of the
pregnancy before the 28th completed weeks of gestation or less than
1000gm weight.
• Unsafe abortion: characterized by lack or inadequacy of skill of
provider, hazardous technique and unsanitary facilities or both.
• Recurrent abortion: three or more consecutive spontaneous
termination of pregnancies.
• Safe abortion: Termination of pregnancy before the time of fetal
viability for the purpose of saving the life of the mother
• Septic abortion: When any of the stages of abortion complicated by
pelvic infection.

07/06/2025 Dr 3
Definition
• It is expulsion or extraction of products of
conception before fetal viability. ( before 28 wks of
gestation or weight <1000 gm(if GA not known) in
Ethiopia ).
• WHO defines gestational age < 20 weeks and weight
<500gm
• Early abortion occurs <=12th gestational week.
• Late abortion occurs between 12 and 20 weeks
gestation.
• In Ethiopia maternal losses from abortion and its
complication account for 25-50%

07/06/2025 Dr 4
Incidence
• Commonest gynecological disorder.
• About 15% of recognized pregnancies end in abortion
and this rise to 30% if unrecognized pregnancies are
included.
• From this 80% occurs b/n 8-12 weeks of gestation
• The frequency doubles from 12% in women younger
than 20 years to 26% in women above 40 years of age.
In Ethiopia 32% of maternal mortality is due to unsafe
abortion.
• In developed countries 95% is safe abortion while in
developing countries above 60% is unsafe abortion
showing that only 40% is safe abortion.

07/06/2025 Dr 5
…
• The vast majority of pregnancy terminations were
performed in the first trimester:
 63 % at----- ≤8 weeks
91 % at----≤13 weeks
7 % -------14 to 20 weeks
1 % at------ ≥21 weeks.
• Potential barriers to early abortion include:,
Delay in recognition and confirmation of pregnancy
Expense
Parental involvement laws
Lack of access to an abortion provider

07/06/2025 Dr 6
Etiologies
A. First trimester abortion
 Fetal chromosomal abnormalities - particularly
 Trisomy ----- 54-67%
 Triploidy------ 16%
 Monosomy ----- 11-15%
• Is the commonest cause of abortion
• 50–70 % of the first trimester abortions are due to
chromosomal abnormalities
• The incidence of these abnormalities increased with the
increase in the maternal age
• Incidence decrease as gestational age increases.
 Anembryonic pregnancy - Blighted ovum
 Multiple pregnancy

07/06/2025 Dr 7
…
 Infections: genital tract infection , systemic
infection with pyrexia & TORCH syndrome
 Endocrine disorders : Diabetes, thyroid disorders
, corpus luteum insufficiency
 Uterine disorders: Uterine anomalies , submucus
fibroid & Asherman’s syndrome.
 Immunological disorders
 Connective tissue disorders
 Cigarette smoking , anaesthetic agents &
chemical agents(cocaine, NSAIDs), alcohol

8
Etiology…
First trimester: Associations:
• Increasing maternal age
• Obesity
• Caffeine
• Alcohol
• Drug misuse
• Fever

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Cont….
Psychological disorders.
Age of the mother
Previous history of spontaneous abortion
 (The risk of miscarriage in future pregnancy is
 20% after one miscarriage,
 28% after two consecutive miscarriages
 43% after >=3 consecutive miscarriages
Multiparity
 Maternal weight—Prepregnancy body mass index
less than 18.5 or above 25 kg/m2 has been associated
with an increased risk of infertility and SAB

Etiology…
B. Second trimester abortion:
1. Multiple pregnancy
2. Cervical incompetence (congenital & acquired )
3. Uterine anomalies and sub mucous fibroid
4. Genital tract infection and PROM If there is PROM before
viability it is called inevitable abortion.
5. Systemic infections: HIV, Malaria, syphilis, Rubella
6. Maternal health: Diabetes, Renal disease,
Hypertension
10

11
Unexplained Abortion
• Unexplained:
The etiology of spontaneous abortion of
chromosomally and structurally normal
embryos/fetuses in apparently healthy women
is unclear.

12
Etiology – Second Trimester
Normal Unicornuate Arcuate
Bicornuate
Septate Didelphic

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DDx
• Abortion
• Ectopic gestation
• Membranous dysmenorrhea
• Hyperestrogenism
• Hydatidiform mole
• Pedunculated leiomyoma
• Cervical neoplasia
• AUB other than Pregnancy
• Local causes
• Urinary tract, GI tract bleeding

14
Classification of abortion
A. Clinically:
1. Threatened abortion
2. Inevitable abortion
3. Incomplete abortion
4. Complete abortion
5. Missed abortion
6. Septic abortion
7. Recurrent abortion

15
Classification…
B. Gestational Age:
1. Fist trimester
2. Second trimester
C. Method
1. Spontaneous
2. Induced

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Clinical Stages of Abortion
Stage Bleeding Cervix Uterine
size
Other Signs
Threatened
abortion
Slight to
moderate
Closed Equal to
date
Abdominal
cramps, soft
uterus
Inevitable or
incomplete
abortions
Slight to
moderate
Dilated Less than
or equal to
date
Cramping
Tender firm
uterus
Leakage of
liquor
bleeding for 7
days or more
Bleeding to
drop in Hgb or
shock
Partial expulsion
of products of
conception
Complete
abortion
Slight to
moderate
Dilated
Less than
or equal to
date
Complete
expulsion of
products of
conception
Missed
abortion
Little or
none
Closed
Less than
or equal to
date
Dead fetus
Decrease in
pregnancy signs
and symptoms

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A. Spontaneous/induced abortion
• Refers to a pregnancy that ends spontaneously
before the fetus has reached a viable gestational
age
• The term spontaneous abortion refers to natural
occurring no elective or therapeutic
(induced)abortion producers
• Induced abortion is the purposeful interruption
of pregnancy by medical or surgical techniques.

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Clinical manifestation
• Women who are actively in the process of having a
spontaneous abortion usually present with a history
of
Amenorrhea
Vaginal bleeding
Pelvic pain.
• On examination, the cervix is open and the products
of conception can be visualized in the vagina or
cervical os, if they have not already been passed.

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CLINICAL TYPES
5. Missed abortion
6. Septic abortion

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Clinical staging of abortion
• Is bleeding of intrauterine origin occurring before the 28th
completed week,
• The term "threatened" abortion is used to describe these cases
because pregnancy loss does not always follow vaginal
bleeding in early pregnancy, even after repeated episodes or
large amounts of bleeding.
• At least 20–30% of pregnant women have some first-trimester
bleeding.
• In most cases this is thought to represent an implantation
bleed.
• U/S which is essential for the diagnosis Showed the presence of fetal
heart activity

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…..
On history
oAmenorrhea
oMild intermitent bleeding(often painless)
oMinimal/mild suprapubic pain
On physical exam
Good general condition.
+ or - uterine contractions,
No cervix change
No expulsion of the products of conception.
Correct uterine size for gestational age.
 It is often not possible to differentiate clinically between threatened abortion,
completed abortion, and ectopic pregnancy in an unruptured tube.

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Threatened abortion (Management)
1. Reassurance If fetal heart activity is present, > 90% of
cases will be progressed satisfactorily
2. Advice: Decrease physical activity (bed rest is of no
therapeutic value), avoid intercourse
3. Hormones i.e. Progesterone & hCG Which are used in the
first trimester to support pregnancy, (but they are of no
proven value)
4. Anti- D: An adequate dose of anti-D should be given to all
Rh –ve,non-immunised patients, whose husbands are Rh +ve
5. ANC as high risk patients
Because those patients are liable to late pregnancy
complications such as APH and preterm labour .

Dr
• A stage of abortion where the changes have progressed to a state from where
continuation of a pregnancy is impossible
• Also known as impending abortion
• On history
Severe bleeding
Sever Abdominal or back pain which follow bleeding
Amenorrhea
• On physical examination
 Poor general condition.
Correct size uterus
Cervix has dilated and effacement
No passage of conception
Sometimes rupture of membrane is noted
It is irreversible.
U/S  Fetal heart activity may or may not present
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Cont.
• Abortion is considered inevitable with two or
more of the following:
1. Moderate effacement of the cervix
2. Cervical dilatation 3 cm
3. Rupture of the membranes
4. Bleeding for 7 days
5. Persistence of cramps despite narcotic
analgesics
6. Signs of termination of pregnancy (e.g.,
absent mastalgia)

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Inevitable abortions
(management)
1. CBC , blood grouping , XM 2 units of blood
2. Resuscitation  large IV line, fluids & blood transfusion
3. Oxytocin drugs  Ergometrine 0.5 mg IM + Oxytocin
infusion (20-40 units in 500 cc saline)
4. Anti D should be given 250IU Im for nonsentisized Rh-
mothers whose husband are Rh+
5. Evacuation & curettage.
6. Post-abortion management.

Dr 26
• Is the expulsion of some, but not all, of the products of
conception.
• The retained products may be part of the fetus, placenta or
membranes.
• In gestations of < 10 wks, the fetus and placenta are usually
passed together, but after 10 wks they may be passed separately
with a portion of the products retained in the uterine cavity
• Features = Heavy bleeding
= lower abdominal pain
= Dilated cervix
= Partial expulsion of products of conception
= Uterus smaller than dates
• U/S  shows retained products of conception ( RPOC )
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….
• On history
Profuse persistent bleeding
Cramps are usually presents
Hx of passing conceptus tissue
• On physical examination sometimes visible or
palpable conceptus tissue through the opening
cervix.
• Rx the same with inevitable

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• All products of conception have been passed without need
for surgical or medical intervention
• Slight bleeding may continue for a short time
• Pain usually cease after pregnancy has traversed the cervix.
• Features = Trace or absent bleeding
= Light lower abdominal pain
= Closed cervix
= History of expulsion of products of conception
= Uterus smaller than dates
• U/S showed empty uterine cavity

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Complete abortion
(Management)
1. Confirm it is complete
2. Post-abortion care

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5. Missed abortion
• A pregnancy in which there is a fetal demise
(usually for a number of weeks) but no uterine
activity to expel the products of conception
• Regress sx /s of pregnancy , Uterine size
decreased, cervix closed, Brownish vaginal
discharge
Complications
Infection, DIC, AF embolism

07/06/2025 Dr 31
….
• Features = Asymptomatic
= There may be history of mild vaginal bleeding
= The uterus may be small for date
= Decrease in pregnancy signs and symptoms
 Stop of fetal movements after 20 weeks gestation.
• Diagnosed accidentally during routine U/S
• U/S shows an embryo with no evidence of heart activity
diagnosed if two ultrasound ( T/V or T/A) at least
7days apart showed an embryo of > 7 weeks gestation (
CRL > 6mm in diameter and gestational sac > 20 mm
in diameter ) with no evidence of heart activity

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Missed abortion (Management)
1. CBC , blood grouping , XM 2 units of blood
2. Platelets count, – to exclude the risk of DIC
NB : DIC does not occur before 5 weeks of
missed abortion or IUFD and if occurred will
be of mild grade

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Missed abortion (Management)
3. Options of treatment
 Conservative treatment:  if left alone spontaneous
expulsion will occur
 Surgical evacuation of the uterus; by D & C:
Indicated in 1st
trimester missed abortion
 Medical termination of pregnancy: by Misoprostol (PGE1)
Cytotec: Indicated in rs missed abortions. 1st
& 2nd
trimester
 Cytotec vaginal ( is the best) or oral tab. 200 μg, 2
tab/ 3 hrs/ up to 5 doses daily, which can be repeated
next day if there is no response in the first day
 Subsequent surgical evacuation is needed in cases of
RPOC
 The main side effects of cytotec are nausea, vomiting
and fever.

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6. Blighted ovum (Anembryonic preg)
• Blighted ovum or an embryonic pregnancy represents
a failed development of the embryo so that only a
gestational sac, with or without a yolk sac, is present.
• An alternative hypothesis proposes that the fetal pole
has been resorbed prior to ultrasound diagnosis
 It is diagnosed if two ultrasound ( T/V or T/A) at
least 7 days apart showed after 7 weeks of gestation
i.e. gestational sac > 20mm , an empty gestational sac
with no fetal echoes seen .
 It is treated in a similar way to missed abortion .

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7. Septic abortion
• Septic abortion:-when any of the stage of abortion complicated
by pelvic infection
• Manifested by
 Fever
 Malodorous vaginal discharge
 Pelvic and abdominal pain
 Cervical motion tenderness fever
 Tachycardia.
• Peritonitis and sepsis may be seen.
• Trauma to the cervix or upper vagina may be recognized if there
has been a criminal abortion.

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DEFINITION OF SAFE AND UNSAFE ABORTION
• WHO defines “safe” abortion as abortion in
countries where abortion law is not restrictive or
countries in which, despite formal law, safe
abortion is broadly available
• Conversely, “unsafe” abortion is performed by
people lacking the necessary skills or using
hazardous technique, and/or in an environment
that does not meet minimum medical standards.
• Spontaneous miscarriages in which sepsis or other
complications occur are also classified as unsafe
abortion.

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….
• Unsafe abortion :-is characterized by lack or
inadequate of skill of provider, hazardous technique
and unsanitary facilities or both.
• 49 % of abortions were classified as "unsafe"
(generally referring to illegal procedures),
• The rate of unsafe abortion in Africa was 97 percent
and in south central Asia was 65 percent.
• Therapeutic abortion :-termination of pregnancy
before the time of fetal viability for the purpose of
saving the life of the mother

07/06/2025 Dr 38
….
• Factors that increase morbidity and mortality at the time of
unsafe abortion include
 Lack of provider skill
 Poor technique
 Unsanitary conditions for performing the procedure
 Lack of appropriate equipment
 Use of toxic substances
 Poor maternal health
 Increasing gestational age
 Lack of access to post-abortion care

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Septic abortion
Bacteriology : Mixed infection
 The commonest organisms are :
1. Gram -ve : E.coli , strepto & staphylococcu
2. Anaerobics : Bacteroides
 Rarely Cl. tetani , which is potentially lethal if
not treated adequately .
Types :
 Mild  the infection is confined to decidua : 80%
 Moderate the infection extended to myometrium
--------------------------15%
 Severe the infection extended to pelvis + Endotoxic
shock + DIC 5%

40
Management :
1. Investigations :
 CBC , blood grouping , 2 units of blood .
 Cervical swabs (not vaginal) for culture and sensitivity
 Coagulation profile , serum electrolytes & blood
culture if pyrexia > 38.5°C
2. Antibiotics : Cephalosporin I.V + Metronidazole I.V
3. Surgical evacuation of uterus  usually 6 - 12 hrs
after antibiotic therapy ( until a reasonable tissue levels of
antibiotics have been achieved )
Septic abortion

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Treatment
• Principle
- Resuscitate patient
- Treat infection
- Evacuate uterus and prevent further infection or organ damage
- Provide counseling
Non pharmacologic
– Evacuate the retained products of conception.
– Do gentle digital curettage followed by the instrumental curettage under
general anesthesia within 6 hours of initiation of antibiotic therapy.
– If there is sign of peritonitis or uterine perforation, laparotomy may be
required
– Psychological support and family planning counseling.
– Blood transfusion when required

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Pharmacologic
• IV fluids as necessary.
If the gestational age is above 14weeks and the fetus is not aborted yet,
Oxytocin,
IV, 20units in 1Lt of N/S to run 50-60drops/min
Ampicillin, IV,1-2 g 6 hourly for 24-72 hours
PLUS
Gentamicin, IV, 80 mg 8 hourly for 24-72 hours
PLUS
Metronidazole, IV,500 mg 8 hourly for 24-72 hours
Switch over from IV to oral therapy when appropriate. Continue with
gentamicin, IM or IV, 80 mg for at least 7 days. (The culture and sensitivity
test results will direct the antibiotic therapy)
Pethidine, IM, 100 mg 4-6 hourly with Promethazine, IM, 25 mg 8-12
hourly
Tetanus prophylaxis, if there is interference with pregnancy under septic
condition.

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Definition
 Is defined as 3 or more consecutive spontaneous abortions
 It may presented clinically as any of other types of
abortions .
Types
 Primary : All pregnancies have ended in loss
 Secondary : One pregnancy or more has proceeded to
viability(>24 weeks gestation) with all others ending in
loss
Incidence
 Occurs in about 1% of women of reproductive age .

07/06/2025 Dr 44
Cont….
Causes
Idiopathic recurrent abortion, in about 50%, in which no cause
can be found .
• The known causes include the followings :
1. Chromosomal disorders:
 Fetal chromosomal abnormalities & structural
abnormalities
2. Anatomical disorders both Aquired and congenital
 Cervical incompetence
 Uterine causes:→ submucous fibroids, uterine anomalies &
Asherman’s syndrome

07/06/2025 Dr 45
Cont…
Causes
3. Medical disorders
 Endocrine disorders : diabetes , thyroid disorders , &
corpus luteum insufficiency .
 Immunological disorders
 Thrombophilia: congenital deficiency of Protein C&S
and antithrombin III, & presence of factor V leiden.
 Infections
 TORCH - CMV may be a cause of recurrent abortion, but
TORH are not causes of recurrent abortion.
 Genital tract infection e.g Bacterial vaginosis
 Rh – isoimmunization

46
Recurrent abortion
Diagnosis :
1. History :
 Previous abortions : gestational age and place of
abortions & fetal abnormalities.
 Medical history : DM , thyroid disorders, PCOS,
autoimmune diseases & thrombophilia.
2. Examination :
 General : weight , thyroid & hair distribution
 Pelvic: cervix ( length & dilatation ) and uterine size.

47
Recurrent abortion
3. investigations :
A. Investigations for medical disorders:
Blood grouping & indirect Coomb’s test in Rh –ve
women
Endocrinal screening: Blood sugar , TFT & LH /FSH
ratio
Immunological screening: Anti anticardiolipine
antibodies & lupus inhibitor.
Thrombophilia screening: Protein C & S,
antithrombin III levels, factor V leiden, APTT and PT.
Infection screening
High vaginal & cervical swabs
ToRCH profile ( which scientifically is not
necessary )

48
Recurrent abortion
B. Investigations for anatomical disorders:
TV/US: fibroids, cervical incompetence &
PCOS.
Hystroscopy or HSG, fibroids, cervical
incompetence, uterine anomalies & Asherman's
syndrome
C. Investigations for chromosomal disorders:
Parental karyotyping: Parental balanced
translocation.
Fetal karyotyping: Fetal chromosomal
anomalies.

49
Recurrent abortion
Management:
In idiopathic recurrent abortion.
With support and good antenatal care , the chance of successful
spontaneous pregnancy is about 60-70%
Support : from husband, family & obstetric staff.
Advice : stop smoking & alcohol intake, decrease physical
activity
Tender loving care
Drug therapy
• Progesterone & hCG: start from the luteal phase & up to 12 weeks.
• Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37
weeks
• LMWH (20-40 mg/day) start from the diagnosis of fetal heart activity & up to 37ws

50
Recurrent abortion
Management:
In the presence of a cause: treatment is directed to control the
cause
Endocrine disorders
• Control DM and thyroid disorders before pregnancy
• Ovulation induction drugs , ovarian drilling or IVF in
PCOS.
• Progesterone or hCG in corpus luteum insufficiency .
:In anti-cardiolipin syndrome:
• Low dose aspirin ( 75 mg/day ) & predinsolone ( 20-30
mg / day), starting when pregnancy is diagnosed till 37
weeks.
• These drugs are not teratogenic.

51
Recurrent abortion
Management:
In thrombophilia:
• Low dose aspirin ( 75 mg/day) starting when pregnancy is
diagnosed and low molecular weight heparin ie LMWH
( 20-40 mg/day) starting when fetal heart activity diagnosed
& to continue both till 37 weeks .
In uterine disorders
• Cervical cerclage in cervical incompetence, best time at the
14 weeks of pregnancy.
• Myomectomy in submucus fibroid, excision of uterine
septum in septate & subseptate uterus & adhesolysis in
Asherman's syndrome.

52
Recurrent abortion
Management:
In infection:: treatment of the genital tract infection.
In Rh isoimmunization: Repeated intrauterine transfusion
In parental balanced translocation
• Explain the risk of fetal chromosomal disorders (~ 30%)
• Encourage to try again or adoption.

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9. Safe abortion
• Indication in our case
1. Incest pregnancy
2. Rape
3. Maternal psychiatric illness
4. Fetal congenital anomaly of the fetus
5. Maternal medical condition that threat maternal life
• Medical safe abortion
– For > 14 weeks of gestational age
• Aspiration
– Up to a maximum of 14 week gestational age
– MVA

07/06/2025 Dr 54
Cont...
1. History
 Previous abortions : gestational age and
place of abortions & fetal abnormalities.
 Medical history : DM , thyroid disorders,
autoimmune diseases & thrombophilia.
2. Examination
 Pelvic: cervix ( length & dilatation ) and uterine
size.

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Principles of Mgt.
• Anti D for RH negative
• Surgical evacuation (E&D or D&C)
 Patient is unstable
 Heavy bleeding
 Septic abortion
 Patient choice
• Medical therapy(misoprostol)
 Missed spontaneous abortion
• Expectant management
• Completed spontaneous abortion
• Incomplete spontaneous abortion??
 Bed rest and pelvic rest
Avoid coitus, douching and strenuous exercise

Uterine Evacuation Methods
• Uterine evacuation removes contents of the
uterus.
• There are several methods for providing first-
trimester uterine evacuation:
– Vacuum aspiration techniques
– Medication (or pharmacological) techniques

Which Method Is Best?
• Use of a certain method depends on:
– Safety, efficacy and cost
– Staff skills
– Equipment, supplies, drugs available
– The woman’s clinical condition
– Woman’s personal preference

59
……..
• 9-12wk MVA is preferred drugs are not
used.
• It is feasibility issue. The capability of
doing the task.
• Because < 9 wk out patient management and
• > 12 wk in patient management b.c
complications are common.

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Medical abortion
Mifepristone
– Is a synthetic anti-progesterone
– Is developed as RU-486
– Leads to detachment of the pregnancy from the uterine wall; it also dilates the cervix
– It is teratogenic if pregnancy continues after use
– Is given orally!
Misoprostol
– Is a prostaglandin E analogue
– Originally manufactured for treatment of PUD
– Works by causing uterine contraction and cervical dilatation
– Can be used for prevention and/or treatment of PPH
– Is given in different roots (oral, vaginal, buccal, sublingual).

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Mechanism of Action: Mifepristone + Misoprostol
Rhythmic
Uterine
Contractions
Progesterone Blockade
Decidual
Necrosis
Cervical
Ripening
Detachment Expulsion
Abortion
© Lisa Penalver
Source: NAF

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Effectiveness of MA
• Combination of two drugs more effective than
either used alone.
• Combined regimen is 92-98% effective in
pregnancies ≤ 9 weeks since LMP .
• Miso alone = 85-90% effective

Medical abortion:
Mifepristone and
misoprostol
Gestational Age Mifepristone Dose Misoprostol Dose, Route and Timing
Up to 9 weeks 200 mg orally After 24-48 hours, 800 mcg buccally, sublingually
or vaginally for one dose
9-12 weeks 200 mg orally After 36-48 hours, 800 mcg vaginally followed by
400 mcg vaginally or sublingually every 3 hours
for a maximum of 5 doses of misoprostol
Above 12 weeks 200 mg orally After 36-48 hours, 400 mcg orally or 800 mcg vaginally
followed by 400 mcg vaginally or sublingually every 3
hours for a maximum of 5 doses of misoprostol,
administered in a healthcare facility

07/06/2025 Dr 64
Regimens
1. Mifepristone
200mg (1 tab) orally on day 1.
– Most women will feel no change after taking mifepristone:
– Some women will begin bleeding before taking the next
pill (misoprostol).
– A few women will abort after the mifepristone alone.

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Regimens
2. Misoprostol
800 (4 tabs) micro gram vaginal suppository
on day 3.
– There is a range of options in route, dosage and timing
– After seven weeks LMP, vaginal doses are more effective
– Up to 90% of women will expel within six hours of
vaginal dose.
Cervical preparation is needed for
• GA> 12 weeks for all patients
• GA< 9 weeks for those age less than 18 years

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….
• If the above dose fails we will wait till 24 hr
from the last dose and restart again with
leaving the repining agent.

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Expected side effects following MA
Pain
Bleeding
Fever, chills, sweating
Nausea, vomiting
Dizziness
Diarrhea
Skin rashes
Headache

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Manual Vacuum Aspiration
69

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Steps of the MVA Procedure
1. Prepare instruments
2. Prepare the woman
3. Perform cervical antiseptic prep
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
72

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MVA Instruments
– MVA aspirator
– Silicone lubrication
– Cannulae (4–12 mm) the cannula size is determined by plus or
minus of the gestational age and start with the smallest then
increase in size progressively
– Adaptor for cannulae
– Specula
– Tenaculum (sharp-toothed or atraumatic)
– Ring forceps
– Antiseptic solution, gauze, and small bowl
– Mechanical dilators
– Syringe, needle, and anesthetic agent for cervical block
73

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Creating a Vacuum
• Begin with valve buttons open, plunger all the way in,
collar stop locked in place
• Close valve by pushing buttons down and forward until
they lock
• Pull plunger back until plunger arms catch on wide
sides of cylinder
• Both arms must be extended, secured over edge of
cylinder
• Incorrect positioning of plunger arms can allow
plunger to slip back into cylinder
74

07/06/2025 Dr
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
76

07/06/2025 Dr
Step 3: Perform Cervical Antiseptic
Preparations
• Follow No-Touch Technique
• Use antiseptic sponges to clean cervix and os
and then, if desired, vaginal walls
• Do not retrace areas previously cleaned
77

07/06/2025 Dr
Step 4: Administer Paracervical Block
• Recommended to administer to all uterine
evacuation clients
• Injection sites vary but technique accepted
globally
• Usually 10–20mL of 0.5%–1.0% lidocaine
(always less than 200mg)
• Always aspirate with needle before injecting
78

07/06/2025 Dr
Administering Paracervical Block
• Inject 1–2mL of anesthetic where tenaculum
will be placed
• Place tenaculum
• Apply slight traction to move cervix, exposing
transition from cervical to vaginal tissue
• Slowly inject 2–5mL of lidocaine into this
tissue to depth of 1–1.5 inches at 3, 5, 7 and 9
o’clock
79

07/06/2025 Dr
Step 6: Insert Cannula
• 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
81

07/06/2025 Dr
When Aspirator is Full
• Close the valve
• Detach the cannula and leave in os
• Open the valve and squeeze plunger arms
• Push plunger and empty the aspirator
• Establish new vacuum
• Reattach to the cannula and continue
83

07/06/2025 Dr
Signs that the Uterus is Empty
1. Red or pink foam without tissue passing
through cannula
2. Gritty sensation over surface of uterus
3. Uterus contracting around cannula
4. Increased uterine cramping and increase pain
intensity
84

07/06/2025 Dr
When the Procedure is Finished
• Push buttons down and forward to close valve
• Disconnect cannula from aspirator OR
• Remove cannula from uterus without
disconnecting
• May evacuate again after inspecting POC
85

07/06/2025 Dr 86
Complications of abortion
• Severe or persistent hemorrhage due to
 Cervical or vaginal lacerations
 Uterine perforation
 Retained tissue
 Uterine atony
• Sepsis develops most frequently after self-induced abortion.
• Infection and infertility
• Rh isoimmunization
• Cervical laceration
• Uterine perforation
• Intra abdominal injury during D&C
- Perforation of the uterine wall may
-Injury to the bowel and bladder

07/06/2025 Dr 87
complications
• Multiple pregnancy with the loss of 1 fetus
and retention of another ("vanishing twin").
• Hematometra
• Psychological distress to mothers.
• Other complications of abortion
-Anemia
- Renal failure
-Infertility(if hysterectomy done
due to complication)

88
Post - abortion management
In cases of incomplete, inevitable, complete, missed
& septic abortions
1. Support: from the husband, family& obstetric
staff
2. Anti D – to all Rh –ve, nonimmunised
patients, whose husbands are Rh+ve
3. Counseling & explanation:
A.Contraception (Hormonal, IUCD, Barrier)
Should start immediately after abortion if the patient
choose to wait , because ovulation can occur 14 days after
abortion and so pregnancy can occur before the expected
next period .

89
B.When can try again:
 Best to wait for 3 months before trying again . This
time allow to regulate cycles and to know the LMP, to give
folic acid, and to allow the patient to be in the best shape
(physically and emotionally) for the next pregnancy
C.Why has it happened
Majority of cases there is no obvious cause
In the first trimester abortion , the most common cause
is fetal chromosomal abnormality

90
D. Can it happen again
 As the commonest cause is the fetal chromosomal
abnormality which is not a recurrent cause , so the chance of
successful pregnancy next time in the absence of obvious
cause is very high even after 2 or 3 abortions
E. Not to feel guilty  as it is extremely unlikely that
anything the patient did can cause abortion
No evidence that intercourse in early pregnancy is
harmful
No evidence that bed rest will prevent it ..

91
PAC: Five elements
1. Emergency treatment of incomplete abortion and
its complications, Rh…
2. Counseling- safe sexual practice, about procedure,
post procedure cxn prevention, when to seek care
etc
3. FP services
4. Screening for STI, HIV, cervical ca.
5. Community-service provider partnership
(community awareness creation)

07/06/2025 Dr 92
Post abortal prophylaxis
• In our set up doxycycline 100mg PO BID for 14
days is given but the standard is a single dose
• Post abortal family planning is also needed and
the type of the family planning technique is
dependent on the maternal will and the event in
pregnancy.
• B/c of fear of uterine perforation in septic
abortion IUCD should be avoided.

07/06/2025 Dr 93
Woman-Centered Post abortion Care
• No women should risk her life in order to
exercise her reproductive choices
• Women centered abortion care includes
-Safe affordable and timely services that are
tailored to women's medical and personal
need
-Respectful and confidential care
-The right to information privacy and range
of choices

07/06/2025 Dr 94
Three Key Elements of AC
• Choice
• Access
• Quality

07/06/2025 Dr 95
Choice
• The right and opportunity to select between options
• The right to determine if and when to become pregnant
• To continue or terminate a pregnancy
• Informed by complete and accurate information
Access
• Trained, technically competent providers
• Up-to-date clinical technologies
• Easy-to-reach services, preferably local
• Affordable and non-discriminatory
• Respectful, confidential services
Quality
• Tailored to each woman’s individual needs
• Using international standards of care
• Offering referrals for other reproductive and health services

07/06/2025 Dr 96
Support Rights in a PAC Setting
– Have empathy and respect for women
– Maintain positive interactions
– Respect privacy and confidentiality
– Adhere to the voluntary, informed consent process

Providing Post abortion Contraception
Method When to Start Remarks
Hormonal Immediate Can be started even if there is
infection or anemia
Condom
IUD
Less than 12 weeks
More than 12 weeks
Immediate or delayed
4–6 weeks after
abortion
If there is infection, delay until it
clears. If hemoglobin is less than
7 g/dL, delay until it improves.
Give an interim method.
Similar to postpartum
Tubal Ligation Immediate
Delayed
Clean procedure
If infection or hemoglobin is less
than 7 g/dL
97

Management of Complications
Uterine perforation
The following signs indicate perforation during uterine
evacuation.
• An instrument (sound, Cannula, Curette) extends beyond the
expected limit of the uterus.
• Fat or bowel is found in the tissue removed from in the
uterus
• Severe pain
• Unstable vital signs
• hypotension in the absence of external bleeding

Management
• Stabilize the patient
• Monitor V/S if unstable –Hypo tension consider immediate
laparatomy
• Start broad spectrum antibiotics (parenteral)
• If evacuation is not complete, Complete evacuation under
direct visual control ( laparatomy)
• If patient become stable and bleeding slow, continue
observation overnight .
If the condition gets worse and the bleeding doesn’t stop, do
Laparotomy / Laparoscopy
• Repair or hysterectomy based on operative findings

Intra abdominal injury
The following signs and symptoms indicate intra
abdominal injury
Symptoms
• Nausea, vomiting
• Shoulder pain
• Fever
• Abdominal pain and cramping

Signs
• Distended abdomen
• Decreased bowel sound
• Tense hard abdomen
• Rebound tenderness
Management
• Resuscitation
• IV antibiotics
• Laparotomy

Sepsis
Etiology is poly microbial
The following symptoms and signs indicates that either local or generalized infection is
likely:
Symptoms
• Chills, fever, sweating
• History of interference
• Prolonged bleeding
• General discomfort, flue like symptoms
Signs
• Foul smelling vaginal discharge
• Distended abdomen
• Tenderness
• Low blood pressure

Management
• Resuscitation
• Monitor V/s
• Start broad spectrum antibiotics IV
• Uterine evacuation
• Continue antibiotics
• Observe for 48 hrs.

07/06/2025
Dr 104
 Thank u
Thank u!!!

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