1. Abortion
Asheber Gaym M.D.
January 2009

2. Outline
• Define abortion
• Brief epidemiology of abortion
• Discuss different categories of abortion
• Discuss etiologies of abortion
• Discuss clinical types of abortion
• Outline diagnosis of abortion
• Outline the management of abortion
• Describe complications of abortion

3. Brief Epidemiology of Abortion
• Spontaneous abortion complicates 10-20% of
pregnancies
• Incidence of induced abortion varies from country to
country based on the availability and accessibility of
contraception
• WHO estimates that there are 80 million abortions
annually of which 40% are unsafely induced
• Nearly 80,000 maternal deaths (20% of total annual
global maternal mortality) is due to unsafe abortions

4. Definition of abortion
• Abortion (miscarriage) is termination of pregnancy before
fetal viability.
• Fetus acquires potential viability starting from a gestational
age of 24 weeks, when the alveolar development and
surfactant production begins in the fetal lungs.
• WHO considers a gestational age of 20 weeks as the cut off
for fetal viability and thus for the definition of abortion
versus delivery
• Different countries use different gestations upto 28 weeks
to consider fetal viability
• A fetal weight of 500 grams or (1000 grams in those who
use a cut of gestation of 28 weeks) is also considered as the
cut off for differentiating abortion from delivery

5. Categories of Abortion
• Based on etiology – Spontaneous versus Induced
abortion
• Based on gestational age – Early (less than 12
weeks) versus Late abortion(greater than
12weeks) – late abortions have more
complication risk than early abortions
• Based on clinical presentations – Different clinical
types
• Based on site of termination in induced abortions
– Safe versus unsafe abortion ( performed by
unskilled person on in an ill equipped setting)

6. Etiologies of Spontaneous Abortion
• Genetic abnormalities – upto 60%
– Chromosomal – trisomies, monosomies, deletions,
translocations etc
– Gene defects
• Infections
– Maternal infections – e.g. malaria, pyelonehpritis etc
– Perinatal infections – e.g. syphilis, mycoplasma, ureaplasma etc
• Uterine factors
– Uterine myomata
– Mullerian abnormalities or defects – septate, bicornuate uterus
etc
– Cervical incompetence

7. • Endocrine abnormalities
– Hypothyroidism ; hyperthyroidism
– Uncontrolled diabetes mellitus
– Luteal phase defects
• Immunological factors – autoimmune diseases
– Antiphospholipid syndrome
• Abdominal trauma

8. Clinical types of abortion
• Threatened abortion
– Minimal vaginal bleeding and lower abdominal
cramps
– Closed cervix and uterine size comparable to
gestational age
– Viable fetus
– 60-80% continue the pregnancy
• Inevitable abortion
– Heavier vaginal bleeding and more severe cramps
– Open cervix but no expulsion of conceptus yet
– Leakage of liquor even without open cervix

9. Clinical types of Abortion
• Incomplete abortion
– Features of inevitable abortion with additional
feature of expulsion of conceptus parts outside
the cervix
• Complete abortion
– complete expulsion of all conceptus parts which
are identified by provider including the fetus,
placenta, membranes and cord
– Uterus well contracted and cervix closed
– Cessation of vaginal bleeding

10. Clinical types of Abortion
• Missed abortion
– Initial symptoms of abortion subside with cessation of
vaginal bleeding and uterine contractions
– Regression of symptoms and signs of pregnancy
– Retention of conceptus within the uterus for more than
two weeks
– Closed cervix and uterine size less than calculated weeks of
amenorrhea
• Recurrent (habitual) abortion
– Three or more consecutive abortions
• Septic (infected) abortion
– Any of the abortion types complicated by infection

11. Diagnosis of Abortion
• Diagnosis of a pregnancy less than fetal viability
• Symptoms
– Vaginal bleeding
– Abdominal cramps
– Leakage of liquor or expulsion of conceptus
– Regression of pregnancy symptoms in missed abortion
• Signs
– Hemodynamic instability
– Vaginal bleeding
– Cervical changes and reduced uterine size
– Visualization of expelled conceptus

12. Diagnostic workup of a suspected abortion
• Hemoglobin ( hematocrit)
• Blood group and RH type
• Pregnancy test if necessary
• Ultrasonography to document fetal viability
• Blood cross match if necessary
• In cases of septic abortion – as required
– WBC and differential
– Coagulation profile
– Liver and renal function tests
– PO2, PCO2 etc as necessary

13. Management of Abortion
• Depends on:
– Clinical type of abortion
– Gestational age: early versus late
– Presence or absence of infection
• Elements of abortion management:
– Medical/surgical management of abortion
– Post abortion family planning
– Counseling
– Linkages with other reproductive health services
– Community partnerships and involvement

14. Medical/Surgical Management
• Threatened abortion
– Bed rest, avoidance of coitus
– Advice to return if heavy bleeding or passage of
conceptus
• Inevitable abortion
– Early – Suction curretage (manual vacuum aspiration)
– Late- Expel conceptus with oxytocin drip and
supplement with curretage as required
• Incomplete abortion
– Early – Suction curretage
– Late – Suction or metallic curretage as convinient

15. Medical/Surgical Management
• Missed abortion
– Early – Suction curretage
– Late- Expel conceptus with oxytocin drip and follow up
with curretage as required
• Recurrent abortion
– Manage accordingly and investigate for possible causes to
avoid recurrence
• Infected or septic abortion
– Cover with broad spectrum antibiotics to cover both gram
positive as well as gram negative aerobic and anaerobic
organisms
– Pelvic infections are often polymicrobial

16. Linkages with other RH services
• Reproductive health problems that are
common in clients requiring abortion care (
particularly unsafe) include:
– Sexually transmitted infections including HIV/AIDS
– Gender based violence including sexual assault
– Family planning
– Infertility
– Reproductive tract cancers particularly cervical ca
– Counseling

17. Complications of Abortion – Before or during
care provision
• Heavy bleeding and shock
• Uterine perforation
• Infection and sepsis
• Infertility later in life – tubal/ Ashermann’s
• Ectopic pregnancy later in life
• Psychological trauma – depression