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Abortion Care.pptxmvfjkhkgkvkhvn.mbvnnbbmbmjnkb bmnnlklnlnh
- 1. Abortion Care BY Jalane.N(OBGYNResident(R1)) Moderator Dr Tsige(OBGYN Consultant) 1 Jalane.N(OBGYN resident)
- 2. Content • INTRODUCTION • INCIDENCE •FIRST-TRIMESTER ABORTION METHODS • SECOND-TRIMESTER ABORTION METHODS • COMPONETS OF COMPREHENSIVE ABORTION CARE • POSTABORTAL CONTRACEPTIVE 2 Jalane.N(OBGYN resident)
- 3. Introduction • Spontaneous orinduced termination of pregnancy before fetal viability • Pregnancy termination-spontaneous or induced-before 20 weeks' gestation or with a fetus born weighing <500 g(CDC,WHO) • Before 28 weeks of gestation or weight <1000 g(Ethiopia) • Safe Abortion care • Post abortion care 3 Jalane.N(OBGYN resident)
- 4. Incidence • 30% to40% of clinical unrecognized pregnancy • 10 to 12% after clinical recognition • Previously had a child is much lower (5%) 4 Jalane.N(OBGYN resident)
- 5. Risk factors • Maternalage • Previous spontaneous abortion • Gravidity • Extremes of maternal weight • Prolonged ovulation to implantation interval • Prolonged time to conception • Nonsteroidal anti-inflammatory drugs • Alcohol, smoking, caffeine • Occupation and Environment 5 Jalane.N(OBGYN resident)
- 6. Etiologies • Fetal chromosomalabnormalities • Multiple pregnancy • Infections • Endocrine disorders • Uterine disorders • Immunological disorders • Connective tissue disorders 6 Jalane.N(OBGYN resident)
- 7. Clinical manifestation • History •Vaginal bleeding • Amenorrhea • Lower abdominal pain • Psychosocial assessment • Physical examination • General Appearance • Vital signs • Abdominal Examination • GUS 7 Jalane.N(OBGYN resident)
- 8. FIRST-TRIMESTER ABORTION METHODS •Medical • Expectant • Surgical 8 Jalane.N(OBGYN resident)
- 9. Medical Abortion • Medicationsare used alone or in combination • Mifepristone • Methotrexate • Misoprostol • Other prostaglandins 9 Jalane.N(OBGYN resident)
- 10. Requirements • FDA requiresthat prescribed only by physicians • Assessment of gestational age • Diagnose ectopic pregnancy • Provide surgical intervention • Access to medical facilities equipped to perform blood transfusions and resuscitation 10 Jalane.N(OBGYN resident)
- 11. Contraindications • Severe anemia •Coagulopathy, or anticoagulant use • Long-term systemic corticosteroid therapy • Chronic adrenal failure • Inherited porphyria • Ectopic pregnancy/GTD • High risk of uterine rupture • Intrauterine device • Allergy to prostaglandins 11 Jalane.N(OBGYN resident)
- 12. Drug interactions • Mifepristonemetabolized by cytochrome P450 3A4 (CYP3A4) • Not correlated with efficacy and ingestion of a single dose in the range of 200 mg up to 800 mg • Mifepristone itself acts as a moderate inhibitor of CYP3A4 metabolism and can thereby alter concentrations of other drugs • Examples include • Immunosuppressants • Calcium channel blockers • Anti-arrhythmics • Analgesic/anesthetic agents 12 Jalane.N(OBGYN resident)
- 13.
- 14. Route of administration •FDA for use as an oral tablet • Buccal administration of misoprostol high efficacy (UPTODATE 2021) • Sublingual administration fastest onset of action and highest plasma level concentration(WHO) • Timing 14 Jalane.N(OBGYN resident)
- 15. Preprocedure evaluation andpreparation • Pregnancy confirmation and gestational age • Sonographic evaluation also allows exclusion of ectopic pregnancy • Counseling and informed consent • Prophylactic antibiotics • 0.3% in 1st TM medical abortion • Antibiotic prophylaxis is not necessary for medical abortion(WHO) 15 Jalane.N(OBGYN resident)
- 16. Follow-up • Final visitwithin two weeks • Ensure that the pregnancy completely expelled • History • Pelvic examination • No Ultrasound examination • HCG values may be informative • When to visit??? 16 Jalane.N(OBGYN resident)
- 17. Complications • Heavy orprolonged bleeding • Unrecognized ectopic pregnancy • Fever • Infection • Incomplete abortion • Teratogenicity • Mortality • Implications for future pregnancy 17 Jalane.N(OBGYN resident)
- 18. Outcome • First-trimester mifepristone/misoprostolabortion is successful in 92 to 98% of procedures • The efficacy varies with several factors • Gestational duration • Route of administration and dose of misoprostol • Parity 18 Jalane.N(OBGYN resident)
- 19. Surgical Abortion • PreoperativePreparation • Cervical preparation for first-trimester • Greater risk of complications from intraoperative cervical dilation • Cervical stenosis • Adolescents • Uterine anomalies • Fibroids 19 Jalane.N(OBGYN resident)
- 20. Vacuum Aspiration • Suctiondilation and curettage or suction curettage • Instrument tray 20 Jalane.N(OBGYN resident)
- 21. Aspiration procedure • Premedications,including antibiotics and analgesics or sedatives • Placing the patient in dorsal lithotomy position empty bladder • Mechanical cervical dilation • Aspiration of the uterine contents with a manual or electric aspirator via a plastic cannula placed in the uterus • Rigid cannula is attached either to an electric-powered vacuum source or to a handheld 60-mL syringe for its vacuum source 21 Jalane.N(OBGYN resident)
- 22. Steps for VA •Bimanual examination is performed to determine uterine size and orientation • Speculum is inserted • Cervix is swabbed with povidone-iodine or equivalent solution • Anterior cervical lip is grasped with a toothed tenaculum • Uterine sounding measures the depth • Appropriate cannula size • Cannulas are sized by diameter • Suction is then activated • Repeated until no more tissue is aspirated • Gentle sharp curettage can follow to remove any remaining tissue 22 Jalane.N(OBGYN resident)
- 23. Recovery and followup • Recovery time is typically 20 to 30 minutes • Assessed for Clinical condition • Warning signs • Vaginal bleeding more than two maxi pads per hour for more than two hours in a row • Cramps that are persistent and worsening despite pain medication • Temperature ≥101°F 23 Jalane.N(OBGYN resident)
- 24. Complications • Uterine perforation(<1%) •Asherman syndrome • Lower-genital-tract laceration • Hemorrhage • Incomplete removal of products • Infection 24 Jalane.N(OBGYN resident)
- 25. Contraindication • Uterine anomaliesand abnormalities • Fibroids impede placement of the cannula at the fundus to reach • Multiple gestations Ultrasound guidance for multiple gestations at an earlier gestational age than for singletons for reassurance of procedure completion • EVA vs MVA 25 Jalane.N(OBGYN resident)
- 26. SECOND-TRIMESTER ABORTION METHODS •10 to 15% of the approximately 42 million abortions • 7.1% of abortions were performed between 14 to 20 weeks • 1.3% at or after 21 weeks • Indications • Fetal anomaly • Fetal demise • Maternal health complications • Preeclamtia • Inevitable abortion 26 Jalane.N(OBGYN resident)
- 27. Procedure planning • Counselingand informed consent • D&E Vs INDUCTION TERMINATION 27 Jalane.N(OBGYN resident)
- 28. Special circumstance • Uterineanomaly • Low-lying placenta • Prior uterine scar • Multifetal gestation 28 Jalane.N(OBGYN resident)
- 29. Cervical preparation • Performeda day or two before the procedure • Preoperative cervical ripening benefits • Less manual intraoperative cervical dilation • Technically easier procedure • Less pain • Shorter operative times 29 Jalane.N(OBGYN resident)
- 30. …con’t • Hygroscopic dilators/Osmotic dilators •Draw water from surrounding tissues • Dilapan-S • Composed of an acrylic-based gel • Expands to an ultimate diameter 3 to 4X 30 Jalane.N(OBGYN resident)
- 31. …con’t • Misoprostol • Doseis 400 μg administered sublingually, buccally, or placed into the posterior vaginal fornix 3 to 4 hours prior to surgery • Oral administration proves less effective and may take longer • Mifepristone • 200 mg given orally 24 to 48 hours before surgery • Cost and greater delay to the procedure • Hygroscopic dilators Vs misoprostol for ripening comparable 31 Jalane.N(OBGYN resident)
- 32. Injection to inducefetal demise • Controversial • Methods used • Division of umbilical cord • Intracardiac potassium chloride • Intrafetal digoxin injection is frequently used prior to cervical ripening 32 Jalane.N(OBGYN resident)
- 33. Dilation and Evacuation •Preprocedure • Anesthesia • Prophylactic antibiotics • Thromboprophylaxis??? 33 Jalane.N(OBGYN resident)
- 34. Technique • Speculum • Cervicaldilation • Drains amnionic fluid or amniotomy • Removing the fetus through cervix with forceps • Disarticulating fetal parts grasped by instrument pulls through cervix • Complete removal of the fetus, a large-bore vacuum curette is used to remove the placenta and remaining tissue • Finally suction and curettage performed to ensure completeness 34 Jalane.N(OBGYN resident)
- 35. …Con’t Sopher uterine forcepsBierer uterine forceps 35 Jalane.N(OBGYN resident)
- 36. Inspect the tissue •All the following components of the pregnancy must be identified • Four extremities • Thorax/spine • Calvarium • Placenta • Fetal and Placental Evaluation 36 Jalane.N(OBGYN resident)
- 37. Second trimester medicalabortion • Cervical preparation • No evidence that osmotic cervical dilation facilitates induction using prostaglandin analogues • Induced fetal demise 37 Jalane.N(OBGYN resident)
- 38. Oxytocin • Fails toinduce labor as effectively as other single agent therapy at midtrimester • 20 to 100 units, infused intravenously over three hours • One hour without oxytocin to allow diuresis • Dosage may be slowly increased to a maximum of 300 units over three hours • Use of other medications • Intra-amniotic injection of ethacridine lactate used commonly in china 38 Jalane.N(OBGYN resident)
- 39. Complications • 0.2 to2% over all • Uterine perforation • Cervical laceration • Uterine bleeding • Postabortal infection • Disseminated intravascular coagulopathy • Amniotic fluid embolism • Uterine rupture 39 Jalane.N(OBGYN resident)
- 40. …con’t Gestational Age NO ofprior uterine scar One prior scar 2 or more prior scar <20week Misoprostol 400mcgV/B/S every three hour Misoprostol 200mcgV/B/S every three hour 20 to 24week Misoprostol 400mcg loading followed by 200mcg V/B/S every three hour Misoprostol 200mcg loading followed by 100mcg V/B/S every three hour 24 to 28 week Misoprostol 200mcg loading followed by 100mcg V/B/S every three hour Misoprostol 100mcg loading followed by 50mcg V/B/S every three hour 40 Jalane.N(OBGYN resident)
- 41. Five Essential Elementsof PAC 1. Management of incomplete abortion and complication 2. Counseling 3. Family planning and Contraception 4. Linkage to reproductive and other health services 5. Community service provider partnership 41 Jalane.N(OBGYN resident)
- 42. Woman-Centered Post abortionCare • 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 42 Jalane.N(OBGYN resident)
- 43. Woman-Centered Post abortionCare • Three Key Elements of AC • Choice • Access • Quality 43 Jalane.N(OBGYN resident)
- 44. Maternal mortality andunsafe abortion • 99% deaths occur in developing country • 1% in developed country • Unsafe abortion 8% of MM • Strategy to prevent maternal mortality • Women empowerment • Changing laws and customs • Broader health service changes • Creating broad participation of all sectors • Value clarification and attitude transformation 44 Jalane.N(OBGYN resident)
- 45. Ethiopia Legal abortionlaw • Cases where law allows termination pregnancy • Rape/Incest • Fetus incurable and serious deformity • Endanger her life or physical health is in danger • Minor who is physically or mentally unprepared for childbirth • Grave imminent danger which can avert by immediate interventions • When and where? 45 Jalane.N(OBGYN resident)
- 46. Counselling • Key toeffective safe abortion and PAC • Privacy and confidentiality • Informed consent • Knowledge, skill and attitude required by counselor • REDI frame work during counselling • Women with special counseling needs 46 Jalane.N(OBGYN resident)
- 47. …cont • Questions askedby women? • When can try again? • Why has it happened? • Can it happen again? • Not to feel guilty? 47 Jalane.N(OBGYN resident)
- 48. POSTABORTAL CONTRACEPTION • Allwomen should be offered family planning method • Essential Elements of postabortal family planning • Counsel clients about their contraceptive needs • Provide information about method options • Support them to choose the FP method • Support the women in addressing their sexual and reproductive health • Ensure the availability of uninterrupted contraceptive supply • Link to higher level facility real if situation requires special treatment 48 Jalane.N(OBGYN resident)
- 49. …con’t • Ovulation mayresume as early as 8 days, but the average time is 3 weeks 49 Jalane.N(OBGYN resident)
- 50. Adolescent friendly abortionservice • WHO 10 to 19 years of age • Barriers in abortion care for adolescent • Counseling young girls 50 Jalane.N(OBGYN resident)
- 51. Linkage to otherreproductive service • Consider the whole person, their social context not solely on specific disease • Identify any other reproductive health services that the woman might need • Tetanus prophylaxis or tetanus booster • Treatment for sexually transmitted infections or • Cervical and breast cancer screening • ANC for future pregnancy • Link to legal areas 51 Jalane.N(OBGYN resident)
- 52. Support Rights ina PAC Setting • Have empathy and respect for women • Maintain positive interactions • Respect privacy and confidentiality • Adhere to the voluntary, informed consent process 52 Jalane.N(OBGYN resident)
- 53. Community provider partnership •Understanding the community • Perception about abortion • Health care workers can play a major role reaching out to community to establish such links • Information to better understand the challenges they face 53 Jalane.N(OBGYN resident)
- 54. Reference • Williams obstetric25th edition • Gabee 7th edition • WHO safe abortion guideline 2018 • Uptodate 2021 • Comprehensive abortion care participant manual 2018 54 Jalane.N(OBGYN resident)
Editor's Notes
- #12 Of note, misoprostol is suitable for early pregnancy failure in those with prior uterine surgery According to observational data regarding obstetric labor induction, misoprostol induction is contraindicated in women with more than one hysterotomy, a prior classical or T-shaped uterine incision, or extensive transfundal uterine surgery. It has not been established whether these risks apply equally to patients undergoing first or second trimester induction
- #15 Vaginal administration of misoprostol due to a possible association with severe infection(Clostridial sepsis )
- #18 Fever(5 to 88%)
- #19 The rate of successful abortion is lower with increasing parity and in women who have had a previous abortion
- #25 Rise with gestational age
- #36 Sopher forceps for pregnancies through 16 to 18 weeks gestational size After 18 weeks of gestation, we prefer the larger Bierer forceps
- #42 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 .