This presentation covers an introduction to Abortion, classification, etiologies, clinical types, diagnostic criteria and basic management. At the end its a detailed discussion of Post abortion management.

1. Abortion and Post abortal care
Azael Haward
azahwrd1@gmail.com
The University of Dodoma
Dodoma, Tanzania
March, 2019
Azael Haward MD 1

2. • Introduction
• Epidemiology
• Classification of Abortion
• Etiology of Abortion
• Clinical types and their manifestations
• Complications of Abortion
• Post abortion care
• References
Azael Haward MD 2

3. Acronyms
PAC - Post abortion care
STIs - Sexual transmitted infections
WHO - World Health Organization
HIV - Human Immunodeficiency Virus
MTP – Medical Termination of Pregnancy
MVA - Manual Vacuum Aspiration
GA - Gestation Age
FH- Fundal Height
FP - Family Planning
Azael Haward MD 3

4. Abortion
It is a spontaneous loss of a fetus before it is viable (has the potential to
survive outside the womb). i.e before 20 weeks
WHO defines it as expulsion or extraction of an embryo or fetus
weighing 500mg or less/approximately 24wks.
For developing countries < 28 weeks
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5. Epidemiology
• The true incidence of spontaneous abortion is not clearly known but at least 15-
20% of all pregnancies end in spontaneous abortion.
• 80% o in the first 12 weeks and the rate decreases rapidly thereafter
• More than 50% of all conception losses in the first 12 weeks are due to
chromosomal anomalies of the zygote, embryo, early fetus or at times the
placenta
• Illegally performed abortions are unsafe, and are important cause of maternal
deaths being responsible for up to 13% of maternal deaths worldwide.
• In Tanzania unsafe abortion contributes up to 4% of all maternal deaths annually.
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6. Classification of Abortions
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7. Other Classification
Type Definition
Early Abortion before 12 weeks
Late Abortion between 12 and 20 weeks
Spontaneous Non induced
Induced Medical(MTP) or Illegal(Unsafe)
Therapeutic Maternal benefit, malformed or dead fetus
Recurrent/habitual ≥2 or 3 consecutive spontaneous abortions
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8. Causes of Abortion
1.Abnormal conceptus
• Chromosomal abnormality- 30-60%
• Structural abnormalities, like neural tube
2.Uterine abnormalities
• Congenital malformations
• Uterine fibroids
• Defects
3.Cervical incompetence
• Second trimester abortions
4.Endocrine diseases
• Luteal phase abnormalities
• Thyroid disease-especially hypothyroidism
• Diabetes mellitus-poorly controlled
5.Infections
• Acute maternal infections leading to
high temperatures
• Transplacental infections including STIs’
6.Toxic/environmental factors
• Smoking
• Alcohol
• Toxins like anesthetic gases, organic
solvents and heavy metals (mercury,
lead)
7. Trauma
• Direct injury
• Diagnostic-amniocentesis
• Major surgery
8. Unknown (40%)
Azael Haward MD 8

9. Stages of abortion
Sometime abortion may occur as series of events with predictable
outcomes, though most patients may come at any stage.
1. Threatened abortion
2. Inevitable abortion
3. Incomplete abortion
4. Complete abortion
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10. Pathophysiology
• Hemorrhage occurs into decidua basalis and necrotic changes in the
tissues adjacent to the bleeding usually accompany abortion.
• The ovum becomes detached and this stimulates uterine
contractions that results into expulsion
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11. Threatened Abortion
Dx Criteria
• Mild vaginal bleeding
• Mild/no lower LAP or back ache
• Cervix closed on digital
examination
Management
• Adequate bed rest at home
• Avoid strenuous activities and sexual
intercourse until all the sx have
subsided
• Schedule a follow up within 7 days
• Return if
o heavy bleeding
o offensive discharge
o Severe abdominal pain
Azael Haward MD 11

12. Inevitable abortion
Diagnostic Criteria
• Moderate or severe per vaginal
bleeding
• Severe LAP
• +/-liquor
• The cervix is dilated with evidence of
imminent expulsion of products of
conception.
• FH may correspond with gestational
age
• Presence of uterine contractions
Management
• Apply ABC
• Hb, BG and X-match
• Give IV RL/NS 2lts (blood if indicated)
• MVA if GA <12 weeks
• Augment the process by administering
Oxytocin 20 IU in 500mls RL/NS at 40-
60 drops/minute if GA > 12 weeks
• Manage as incomplete/incomplete
abortion if after augmentation some
products of conception
remain/expelled
Azael Haward MD 12

13. Incomplete Abortion
Dx Criteria
• Cramping LAP
• Slight/profuse PV bleeding a/w
clots/products of conception
• Clots/ products of conception
protruding through the cervical
• Fundus smaller than dates
• The cervix is dilated and products
of conception may be felt in the
cervix on digital examination
Management
• Apply ABC
• Hb, BG and X-match
• Give IV RL/NS 2lts (blood if
indicated)
• Digital evacuation of products of
conception
• MVA if GA <12 weeks
• D&C if GA >12 weeks
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14. Complete Abortion
Dx Criteria
• Minimal or no PV bleeding
• Uterus smaller than dates and
often well contracted.
• Cervix may or may not be closed
Management
• Amoxicillin PO 500 mg tds for 5/7 and
• Metronidazole PO 400mg tds 5/7 and
• FeFol one tablet bd for 3/12 months
and reassess after every 4 week’s
If in shock manage accordingly!
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15. Septic Abortion
Dx Criteria
• Abdominal pain following history of abortion
• +/- Fever
• PV discharge +/- blood.
• +/- shock or/and jaundiced
• Tender uterus, rebound tenderness
• Cervix is usually open
Management
• FBC
• BT if indicated
• endocervical swab for C&S
• Evacuate the uterus with sharp wide curette
under GA
Pharmacology
• Ampicillin 1g IV 6 hourly for 24-48 hours AND
• Metronidazole IV 500mg 8 hourly for 24-48 hours AND
• Gentamicin 80mg IV 12 hourly for 7days
• After C&S result treat accorgingly
 If in shock treat accordingly
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16. Molar Pregnancy /Abortion
Diagnostic Criteria
• Vaginal bleeding
• Uterus > GA, fetal parts not
palpable.
• Severe nausea and vomiting
• Vaginal discharge grape like
• Very heavy vaginal bleeding
when the mole abort
spontaneously
Management
When detected it should be treated
right away.
Azael Haward MD 16

17. Missed Abortion
Diagnostic criteria
• History of amenorrhea
• Regression of the pregnancy symptoms
• Uterine < GA
• Mild PV bleeding
Management
Investigations
• Abdominal pelvic USS
• FPC
Pharmacological treatment
• Induce with misoprostol if > 12wks
• Evacuate if < 12WKS
After evacuation;
• Amoxicillin (PO) 500mg 8hly for 5 days
and
• Metronidazole (PO) 400mg 8hly for 5 days
Azael Haward MD 17

18. Complications
• Anemia
• Sepsis
• Depression
• Perforation
• BT complications (HIV. Hep, Incompatibility)
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19. Postabortal Care (PAC)
For women/girls who wants child immediately after abortion, WHO
recommend waiting for at least 6 months.
The original concept for PAC was first articulated by Ipas in 1991 and
published by the PAC
Is an approach for reducing morbidity and mortality from complications
of unsafe and spontaneous abortion.
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20. Components
The original PAC 1994 Components
• emergency treatment for
complications of spontaneous or
induced abortion;
• post abortion FP counseling and
services; and
• linkages between emergency
care and other reproductive
health services
Updated PAC 2004 Components
• Emergency treatment for
complications of abortion
• FP counselling (treat STIs and
HIV Counselling when possible)
• Community empowerment
(awareness and mobilization)
it is easier to market and describe.
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21. CORE COMPONENTS OF THE USAID PAC MODEL
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22. Five PAC essential elements:
1. Treatment
2. Counseling
3. Contraceptive + family planning services
4. Reproductive and other health services.
5. Community + service provider partnerships
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23. Treatment
• Treatment of incomplete and unsafe abortion and complications that
are potentially life threatening is an important component of PAC.
• In many cases, an incomplete abortion will need to be treated by
uterine evacuation.
• Complications may be potentially life threatening if prompt and
appropriate medical attention is lacking.
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24. Counselling
• Effective counseling - permeate every component of services, from
1st contact between the woman and provider to the last contact.
• Women and service providers - identify and address broader
emotional and physical health and other needs and concerns.
• Providers should be able to respond or provide referrals within their
service network.
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25. Counseling cont
Aims:
• Solicit and affirm women's feelings and provide emotional support
• Appropriate answers to questions or information on medical conditions, test
results, treatment and pain management options and follow-up care, and that
they understand how to prevent post-procedure complications and when and
where to seek care for complications if they arise
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26. Counseling cont
• Help women clarify their thoughts about their pregnancy, incomplete
abortion, treatment, resumption of ovulation and reproductive health
future
• Listen and ask questions to help the provider better understand and
respond to other needs and concerns that could potentially impact
their care, eg. if infected with HIV, have STIs or are at, or if women are
survivors of sexual or gender-based violence
• Address other concerns women may have
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27. 3. Contraceptive + Family planning services
• Many women of childbearing age would want to delay/avoid
pregnancy, or practice birth spacing, but are not using contraception.
• Access to a wide range of contraceptive methods to prevent
unwanted pregnancy and help women to practice birth spacing,
including emergency contraception where authorized, are effective
strategies for preventing future unwanted pregnancies and unsafe
abortion and helping women achieve their reproductive goals.
Azael Haward MD 27

28. Contraceptive + Family planning
• For women who do not desire pregnancy if not offered contraceptive
methods in the same facility may not return or follow up on a referral
for provision of a contraceptive method.
• For women who desire pregnancy, family planning services still
essential for ensuring adequate spacing for healthy pregnancies and
healthy children.
Azael Haward MD 28

29. 4. Reproductive and other health services
• Include reproductive and other health services provided on-site at the facility where treatment
has taken place, or via referrals to other accessible facilities.
• Reinforce connections among services and establish mechanisms for ensuring that women in
need get them.
• Recognize the loss to follow-up for referrals, encourage provision of post abortion care and other
health services at the same facility as treatment services, when possible and appropriate.
• When not possible for a facility to provide needed additional services, functional referral and
counter-referral systems and follow-up mechanisms eg record keeping, should be established or
improved and monitored to ensure that women's needs are being met.
Azael Haward MD 29

30. Reproductive and other health cont
Other health services may include:
• STI/HIV prevention education, screening, diagnosis and treatment
• screening for sexual and/or domestic violence, immediate treatment as needed, and referral for
medical/social/economic services and support
• screening for anemia, and treatment and/or nutrition education
• infertility diagnosis, counseling and treatment
• hygiene education
• cancer screening and referral, as needed
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31. 5. Community and Health care provider
partnership
• Community members play a vital role in reduction of maternal
morbidity and mortality and improving women's sexual and
reproductive health and lives.
• To achieve universal local access to sustainable, high-quality PAC and
other health services, community members, lay health workers and
traditional healers and formally trained service providers must work
in partnership.
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32. Checklist
• Introduction
• Types and Classification of Abortion
• Etiology
• Specific types and their manifestations
• Post abortion care
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33. References
• DC Dutta Textbook of Obstetrics 7th Edition 2014
• Abortion and Family Planning in Tanzania by Ross E. J. Kinemo
• USAID Post Abortion Care Model 2004
• Tanzania Standard Treatment and Guidelines 2017
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