management of abortion

1. ABORTION/MISCARRIAGE
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ABORTION
• Expulsion of product of conception (poc) or fetus before age of
viability.
• May be spontaneous or induced.

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CAUSES
• Genetic factors
• Infection
• Endocrine and metabolic factors
• Immunological
• Anatomical factors
• Others e.g. Blood group incompatibility,prom, cigarette smoking
• Unexplained/idiopathic

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CLASSIFICATON
• Spontaneous
• Induced
-legal
-illegal

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SPONTANEOUS ABORTION
• Threatened
• Inevitable
• Complete
• Missed
• Septic

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THREATENED ABORTION
• Process of abortion has started but has not progressed to a
state from which recovery is impossible.

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THREATENED ABORTION -clinical evaluation
• Minimal pv bleeding
• Minimal or no abdomen pains
• Cervical os closed
• Uterus size corresponds to gestational age.
• viable fetus

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management of THREATENED ABORTION
investigations
• U/S for viability
• BLOOD (Hb, ABO, RH serum progesterone)
management
• Expectant management
- No specific treatment (self-limiting condition)
- Excessive work is discouraged
- Avoid coitus

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INEVITABLE ABORTION
• Process of abortion has progressed to a state from where
continuation of pregnancy is impossible.

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INEVITABLE ABORTION- clinical evaluation
• Increased vaginal bleeding or draining
• Increased abdominal pains
• Progressive Cervix dilatation/Open cervix
• Crampy pelvic pain
• Uterine size correspond to gestational age

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management of INEVITABLE ABORTION
• Correct shock if present
• Accelerate expulsion/ Await expulsion
• Maintain strict asepsis
• Evacuate uterus if Retained product of conception.

12. For gestation < 14 weeks
• Manual vacuum aspiration (MVA) with analgesia
• Doxycycline 100 mg PO OD and metronidazole 400 mg PO BD for 48
hrs total.

13. For gestation ≥ 14 weeks
• Expedite expulsion with oxytocin if absent membranes
• Analgesia
• Doxycycline 100 mg PO OD and metronidazole 400 mg PO BD until 48
hrs after MVA
• Evacuation of retained POCs after expulsion
• Sieve and inspect specimen after evacuation of retained POCs

14. management of INEVITABLE ABORTION
• Bereavement counselling and family planning
• Link to other sexual and reproductive health (SRH) services
• Send specimen for histopathology and karyotype

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COMPLETE ABORTION
• Product of conception (POC) are expelled completely
• Abdominal pains cease
• PV bleeding ceases
• Uterus smaller, bulky than the gestation age

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• Cervix os closed
• Bleeding is trace or minimal PV bleeding
• history of having passed Product of conceptions

17. COMPLETE ARBOTION -clinical evaluation
• blood for Hb, group and save
• Do ultrasound scan if in doubt and or confirmatory empty uterus

18. management of COMPLETE ABORTION
• If first trimester loss and at risk for alloimmunisation, then lower
dose of anti-D is acceptable
• If febrile or infection suspected, then doxycycline 100 mg PO OD and
metronidazole 400 mg PO BD for 48 hrs
• Offer anti-D in Rh negative women.
• Treat shock if present

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INCOMPLETE ABORTION
• Part of product of conception (POC) retained inside uterine cavity
• Commonest type.

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INCOMPLETE ABORTION -clinical evaluation
• History of expulsion of product of conceptions.
• Continuation of colicky lower abdominal pains.
• Persistence and or profuse of PV bleeding.
• Pelvic pain
• Open cervix
• Uterine size smaller than gestation age
• Product of conceptions present or felt at cervical os

21. INCOMPLETE ABORTION -clinical evaluation
• blood (Hb, group and save,/x-match)

22. management of INCOMPLETE ABORTION
If shock, then resuscitate with IV fluids and/or Blood transfusion
Medical management with misoprostol 600 mcg PO or 400 mcg SL one dose
to start
Surgical management
-MVA with analgesia
- Doxycycline 100 mg PO OD and metronidazole 400 mg PO BD for 48 hrs

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management of INCOMPLETE ABORTION
• post-abortal care
• Bereavement counselling and family planning
• Link to other Sexual related and health services
• Send specimen for histopathology and karyotype if available

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MISSED ABORTION
• Fetus is dead and retained inside the uterus for a variable
period.
• non viable pregnancy that has not yet been expelled or IUFD

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MISSED ABORTION- clinical evaluation
• Persistence of brownish vaginal discharge or dirty vaginal
discharge
• Subsidence of pregnancy symptoms.
• Cessation of uterine growth.
• Non- viable fetus
• Closed cervix

26. MISSED ABORTION- clinical evaluation
• blood (Hb, Group & save)
• Bedside clotting test
Ultrasound:
- non-viable pregnancy or empty sac or IUFD
- may be repeated if gestation age < 8 wks

27. management of MISSED ABORTION
 Medical management
• For first trimester gestation: misoprostol 800 mcg PV every 3hours,
max 2 doses, or 600 mcg SL every 3 hours, max 2 doses
• For 13-17 weeks gestation: misoprostol 200 mcg PV every 6hours,
max 4 doses
• For 18-26 weeks gestation: misoprostol 100 mcg PV every 6hours,
max 4 doses

28. Surgical management
• For first trimester gestation: Misoprostol 400 mcg PV 3 hrs or SL 2-3 hrs before
procedure
- MVA with analgesia (i.e. cervical block)
• For second trimester gestation: Misoprostol 400 mcg PV 3 hrs or SL 2-3 hrs
before procedure
- Evacuation of retained POCs in OT under general anaesthesia

29. • Bereavement counselling and family planning
• Send specimen for histopathology and karyotype if available

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SEPTIC ABORTION
• Any abortion associated with clinical evidence of infection of
the uterus and its contents.
• Majority of cases associated with incomplete abortion

31. complications of SEPTIC ABORTION
Immediate
- hemorrhage
- injury
- spread of infection.
Late
- chronic Pelvic pain,
- 2nd infertility,
- ectopic pregnancy,
- emotional depression

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SEPTIC ABORTION- clinical evaluation
• May be history of illegal abortion or Possible pregnancy
interference
• Rise in temperature ≥38
• maternal pulse rate > 100 b/m
• Offensive or purulent vaginal discharge.
• Evidence of pelvic infection –tender lower abdomen.

33. SEPTIC ABORTION- clinical evaluation
• Admit patient
• FBC with differential
• Group & save and or X-match if needed
• Bedside clotting time
• Endocervical swab or HVS

34. management of SEPTIC ABORTION
Medical management
• Ergometrine 0.5 mg IM (or syntometrine) on admission
• Adequate resuscitation: IV fluids and/or Blood transfusion
• analgesia
• Monitor vital signs and urine output
• Ampicillin 500 mg IV QID, gentamicin 80 mg IV TDS, metronidazole 500 mg IV
TDS starting ideally 8 hrs pre-MVA and for total of 14 days

35. Surgical management
- MVA by experienced DOCTOR under GA (high risk for perforation)
• Send specimen for histopathology, microbiology, and karyotype if
available
• Watch out for coagulopathy

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SEPTIC ABORTION - prevention
• Expand family planning Services.
• Offer safe abortion services.
• Aseptic techniques.

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RECURRENT MISCARRIAGES
• Sequence of three or more consecutive spontaneous
abortions.

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RECURRENT MISCARRIAGES
• Management is directed at the cause.

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TWALUMBA
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