Abortion. slideshare including treatment

 Abortion
 Incidence
 Etiology
 Types of abortion
 Recurrent miscarriages
 Therapeutic abortion
 Case presentation
2

 Abortion is the expulsion or extraction of an embryo or fetus
weighing 500 g or less from its mother when it is not capable of
independent survival (i.e. before the period of viability)
3

 10–20% of all clinical pregnancies
 75% abortions occur before the 16th week
 Rates vary with maternal age; also high in women with past
miscarriages
4

 Fetal Factors
 Maternal Factors
6

 Genetic
 50% of early miscarriage is due to chromosomal abnormalities
 Numerical defects like Trisomy, Polyploidy, Monosomy
 Structural defects like translocation, deletion, inversion
 Multiple Pregnancies
 Degeneration of villi
7

 ENDOCRINE AND METABOLIC FACTORS (10–15%):
 Luteal Phase Defect
 Thyroid abnormalities
 Diabetes mellitus
 Anatomical abnormalities (10–15%)
 Cervicouterine factors
 Cervical incompetence & insufficiency
 Congenital malformation of the uterus
 Uterine Fibroid
 Intrauterine adhesions
8

 Infections (5%)
 Viral: rubella, cytomegalo, HIV,..
 Parasitic: toxoplasma, malaria,..
 Bacterial: ureaplasma, chlamydia,..
 IMMUNOLOGICAL DISORDERS (5–10%)—
 Autoimmune disease
 Alloimmune disease
 Antifetal antibodies
9

 Environmental Factors
 Cigarette smoking
 Alcohol consumption
 Contraceptive agents
 Maternal medical illness
 Cyanotic heart disease
 Hemoglobinopathies
 Unexplained (40-60%)
 In majority, the exact cause is not known.
10

 Condition in which miscarriage has started but has not
progressed to a state from which recovery is impossible
11

 The patient, having amenorrhea, complains of:
(1) Slight bleeding per vaginam
(2) Pain: Usually painless; there may be mild backache or dull
pain in lower abdomen
12

 The uterus and cervix feel soft.
 Digital examination reveals closed external os
 Differential diagnosis includes
 cervical ectopy
 polyps or carcinoma
 ectopic pregnancy
 molar pregnancy
 Ultrasound is diagnostic; Pelvic examination is avoided when
USG is available
13

 Rest: Patient should be in bed for few days until bleeding stops
 Relief of pain: Diazepam 5 mg BD
 80% of pregnancies with threatened abortions go on until term
 If a live fetus is seen on USG, pregnancy is likely to continue in
over 95% cases.
 If pregnancy continues, there is increased frequency of preterm
labor, placenta previa & IUGR
15

 It is the clinical type of abortion where the changes have
progressed to a state from where continuation of pregnancy is
impossible.
16

 The patient, having the features of threatened miscarriage,
presents with
 vaginal bleeding
 Aggravation of colicky pain in the lower abdomen
 Sometimes, the features may develop quickly without prior
clinical evidence of threatened miscarriage
 Internal examination reveals dilated internal os through which
the products of conception are felt
17

 Management is aimed:
 To accelerate the process of expulsion
 To maintain strict asepsis
 If pregnancy < 12 weeks, suction evacuation is done
 If pregnancy > 12 weeks, expulsion by oxytocin infusion
 General measures:
 Excessive bleeding is controlled by administering methergin 0.2 mg
 Blood loss is corrected by IV fluid therapy and blood transfusion
19

 A. If patient is in shock or bleeding is severe
 IV fluids and blood transfusion as necessary
 B.To relieve severe pain Evidence Rating: [C]
 Morphine, IV, 2.5-5 mg 4 hourly as required AND
 Metoclopramide, IV, 5-10 mg 8 hourly as required for vomiting OR
 Pethidine, IM, 75-100 mg stat. THEN
 50-100 mg 6-8 hourly if required AND
 Promethazine, IV/IM, 25 mg as required (max. 25 mg 6 hourly) as
required to reduce the chances of vomiting and to potentiate the
analgesic effect of Pethidine
20

 C.Evacuate uterus
 If uterine size > 12-14 weeks Evidence Rating: [A]
 Oxytocin, IV, 10-20 units per litre of Normal saline
 Or
 Uterine size <12 weeks Evidence Rating: [C]
 Misoprostol, oral/SL, 600 microgram stat.
 D. To Prevent Infection
 Amoxicillin, oral, 500 mg 8 hourly for 5-7days
 And
 Metronidazole, oral, 400 mg 8 hourly for 5-7days
21

 E. To prevent Rhesus Isommunization in Rhesus negative
women Evidence Rating: [A]
 Anti D Rh Immune Globulin, IM, 300 microgram (1,500 Units),
stat. within 72 hours of abortion
22

 The process of abortion has already taken place, but the entire
products of conception are not expelled & a part of it is left
inside the uterine cavity
23

 History of expulsion of a fleshy mass per vaginam;
 Continuation of pain in lower abdomen
 Persistence of vaginal bleeding
 Internal examination reveals
 uterus smaller than the period of amenorrhea
 Open internal os
 varying amount of bleeding
 On examination, the expelled mass is found incomplete
Complications:
 The retained products may cause:
(a) bleeding (b) sepsis or (c) placental polyp.
24

 Evacuation of the retained products of conception (ERCP)
 Early abortion: Dilatation and evacuation under analgesia or
general anesthesia is to be done.
 Late abortion: Uterus is evacuated under general anesthesia and
the products are removed by ovum forceps or by blunt curette.
In late cases, D&C is to be done to remove the bits of tissues
left behind.
 Prophylactic antibiotics are given; removed materials are
subjected to a histological examination.
 Medical management - Tab. Misoprostol 200 μg is used vaginally
every 4 hours
26

 A. If in shock and/or severe bleeding
 B. Abortion with uterine size < 12 weeks Evidence Rating: [A]
 Ergometrine, IM/IV, 500 microgram stat.
 Or
 Misoprostol, oral, 600 microgram stat.
 Or
 Misoprostol, sublingual, 400 microgram stat.
27

 C. Abortion with uterine size > 12 weeks and ≤ 24 weeks Evidence
Rating: [A]
 Misoprostol, oral, 600 micrograms stat.
 Or
 Misoprostol, sublingual, 400 micrograms stat.
 D. Abortion with uterine size > 24 weeks Evidence Rating: [B]
 Oxytocin, IV, 20 units into 1 L of Sodium Chloride 0.9% and infuse at 30-60
drops per minute
 Or
 Or
28

 E. To prevent infection
 Amoxicillin, oral, 500 mg 8 hourly for 5-7days
 And
 F. To prevent infection – in patients with penicllin allergy
 Erythromycin, oral, 500 mg 8 hourly for 5-7days
 And
 G. To prevent Rhesus Isommunization Evidence Rating: [A]
29

 When the products of conception are completely expelled from
the uterus, it is called complete miscarriage.
30

 There is history of expulsion of a fleshy mass per vaginam
followed by
 Subsidence of abdominal pain
 Vaginal bleeding becomes trace or absent
 Internal examination reveals:
 Uterus smaller than the period of amenorrhea
 Cervical os is closed
 Bleeding is trace.
 Transvaginal sonography confirms that uterus is empty
31

 The fetus is dead and retained passively inside the uterus for a
variable period
 It is diagnosed when there is a fetus with a crown rump length
of 5mm without a fetal heart.
32

 The patient usually presents with features of threatened
miscarriage followed by:
 Subsidence of pregnancy symptoms
 Uterus becomes smaller in size
 Cervix feels firm with closed internal os
 Nonaudibility of the fetal heart sound even with Doppler ultrasound
 Immunological test for pregnancy becomes negative
33

 Retaining the products for long time can lead to sepsis
 DIC [Disseminated Intravascular Coagulation]
 (very rare) in gestations exceeding 16 weeks
34

Uterus is less than 12 weeks:
 Prostaglandin E1 (Misoprostol) 800 mg is given vaginally and
repeated after 24 hours if needed. Expulsion usually occurs
within 48 hours
 Suction evacuation is done when the medical method fails
Uterus more than 12 weeks
 6th or 12th hourly misoprostol tablets given vaginally
 If this fails, extraamniotic instillation of ethacridine lactate is
used
 Antibiotics are given
35

 A. Ripening of cervix to facilitate surgical evacuation Evidence Rating:
[A]
 Misoprostol, oral or vaginal, 400 micrograms stat. at least 3 hours prior to
surgical evacuation
 B. Emptying uterus with Medication in Missed Abortion
 Misoprostol 800 microgram vaginally if needed repeat dose in 24 to 72 hours
 OR
 Misoprostol 600 microgram sublingually followed by two additional doses if
needed 3 hourly
 Or Evidence Rating: [B]
 Oxytocin drip may be used for induction where other cervical ripening
methods (e.g. Foleys catheter balloon) are used
36

 Any abortion associated with clinical evidences of infection of
the uterus and its contents
 Most common cause
 Attempt at induced abortion by an untrained person without the use
of aseptic precautions
37

 Grade–I: The infection is localized in the uterus.
 Grade–II: The infection spreads beyond the uterus to the
parametrium, tubes and ovaries or pelvic peritoneum.
 Grade–III: Generalized peritonitis and/or endotoxic shock or
jaundice or acute renal failure.
Grade-I is the commonest and is usually associated with
spontaneous abortion
38

 Fever, abdominal pain and vomiting or diarrhoea
 A rising pulse rate of 100–120/min or more is a significant
finding than even pyrexia. It indicates spread of infection
beyond the uterus.
 Examination shows abdominal tenderness, guarding, rigidity
 Internal examination reveals:
 offensive purulent vaginal discharge
 tender uterus usually with patulous os or a boggy feel
 Soft cervix with open internal os
39

 CBC
 Serum urea, creatinine, electrolytes
 High vaginal swab
 Blood culture in suspected septicaemia
 Pelvic USG to detect retained products of conception
 X-ray abdomen in suspected bowel injury
 X-ray chest if there is difficulty in respiration
40

Immediate:
 Hemorrhage
 Injury to uterus & adjacent structures
 Spread of infection leads to:
 Generalized peritonitis
 Endotoxic shock—mostly due to E. Coli
 DIC
 Acute renal failure
 Thrombophlebitis.
 All these lead to increased maternal deaths
41

 Mild cases –
 Broad spectrum antibiotics started
 Uterus is evacuated
 Severe Cases
 Vigorous IV infusion with crystalloid
 Oxygen given by nasal catheter
 Broad spectrum antibiotics – combination of ampicillin, gentamicin,
metronidazole is started
 Uterus is evacuated in 4-6 hrs of commencing therapy.
42

 A. Resuscitation for shock Evidence Rating: [A]
 B. Treatment of Sepsis
 Amoxicillin + Clavulanic Acid, IV, 1.2 g 8 hourly for 24-72 hours
 And
 Gentamicin, IV, 80 mg 8 hourly for 5 days
 And
 Metronidazole, IV, 500 mg 8 hourly for 24-72 hours
43

 C.Evacuate uterus
 If uterine size > 12-14 weeks Evidence Rating: [A]
 Oxytocin, IV, 10-20 units per litre of Normal saline
 Or
 Misoprostol, oral, 600 microgram stat.
 Or
 Misoprostol, sublingual, 400 microgram stat.
44

 D.Severe Pain management Evidence Rating: [C]
 Morphine, IV, 2.5-5 mg 4 hourly as required
 And
 Metoclopramide, IV, 5-10 mg 8 hourly as required for vomiting
 Or
 Pethidine, IM, 50-100 mg 4-6 hourly (Maximum 400 mg in 24 hours)
 And
 Promethazine, IV/IM, 25 mg 8-12 hourly as required (max. 25 mg 6
hourly) to reduce the chances of vomiting and to potentiate the
analgesic effect of Pethidine
45

 E. Tetanus Prophylaxis
 Tetanol, IM, 0.5 ml stat.
 And
 Human Immune Tetanus Globulin, IM, 250-500 units stat.
46

 Recurrent miscarriage is defined as a sequence of three or more
consecutive spontaneous abortion
 Seen in ~ 1% of all women
 Risk increases with each successive abortion
 No underlying cause is found for 50% of recurrent pregnancy loss
48

FIRST TRIMESTER ABORTION:
 Genetic factors (3–5%):
 Parental chromosomal abnormalities
 The most common abnormality is a balanced translocation.
 This leads to unbalanced translocation in the fetus, causing early
miscarriage or a live birth with congenital malformations
 Risk of miscarriage in couples with a balanced translocation is > 25%.
 This is the most common cause for 1st trimester loss
49

 Endocrine and Metabolic:
 Poorly controlled diabetic patients
 Presence of thyroid autoantibodies
 Luteal phase defect
 Hypersecretion of luteinizing hormone (e.g. in PCOS).
 Infection:
 Infection in the genital tract - (Transplacental fetal infection)
 Syphilis
 Inherited thrombophilia
 Protein C deficiency, Protein S deficiency, factor V Leiden mutation,
prothrombin gene mutation
50

 Immunological cause:
Autoimmunity – Antiphospholipid antibody syndrome(15%).
 Antiphospholipid antibodies present in mother produce adverse
fetal outcome
 Diagnosis by presence of lupus anticoagulant/IgG/IgM
anticardiolipin antibodies
Alloimmune factors
 Immune response against paternal antigens in the fetus
 This is a result of lack of production of blocking antibodies by
the mother due to failure of recognition of TLX
51

SECOND TRIMESTER MISCARRIAGE:
 Anatomic abnormalities - responsible for 10– 15% of recurrent
abortion.
 Causes may be
(a) Congenital - defects in the mullerian duct fusion (e.g.
unicornuate, bicornuate, septate or double uterus)
(b) Acquired - intrauterine adhesions, uterine fibroids and
endometriosis, cervical incompetence
52

 Defects of mullerian fusion
 Double uterus, septate or bicornuate uterus
 About 12% cases of recurrent abortion.
 Implantation on the septum leads to defective placentation
 Asherman syndrome
 Intrauterine adhesions due to previous curettage – can lead to early
miscarriage
 Transvaginal ultrasound is used for diagnosis;
 Hysteroscopic resection for septum or division of adhesions in
Asherman’s syndrome.
 Submucous fibroids - managed by myomectomy
53

 Painless cervical dilatation with ballooning of amniotic sac into
vagina, followed by rupture of membrane and expulsion of fetus
 Usually at 16 – 24 weeks
56

 Congenital – Developmental weakness of cervix – Uterine
anomalies
 Acquired (iatrogenic)—common, following:
 (i) D&C operation
 (ii) Induced abortion by D and E
 (iii) vaginal operative delivery through an undilated cervix
 (iv) amputation of the cervix or cone biopsy.
 Multiple gestations, prior preterm birth.
57

 History - Repeated mid trimester painless cervical dilatation
and escape of liquor amnii followed by painless expulsion of the
products of conception
 Internal examination: Interconceptual period:
 Passage of no. 6–8 Hegar dilator beyond the internal os without any
resistance or pain
 Funnelling of internal os seen in hysterosalpingography
58

 During pregnancy
 Clinical digital – Painless cervical shortening and dilatation
 Sonography: Trans vaginal ultrasound is performed. Short cervix
< 25 mm; Funnelling of the internal Os > 1 cm.
59

 Surgical management – Cervical cerclage
 Usually at 12-14 weeks
 The procedure reinforces the weak cervix by a non-absorbable
tape, placed around the cervix at the level of internal os.
60

 Contraindications
 Intrauterine infection
 Ruptured membranes
 History of vaginal bleeding
 Severe uterine irritability
 Cervical dilatation > 4 cm.
 2 main methods – McDonald and Modified Shirodkar
 Success rates - 80 – 90%
63

 History Indicated
 Definite history of 3 previous second trimester losses/ preterm births
 Ultrasound indicated
 Short ended cervix or early funnelling in ultrasound in a woman with
1 or 2 spontaneous losses
 Examination indicated / Rescue cerclage
 Performed after the cervix is found dilated
 Also called emergency cerclage
64

I. McDONALD’S OPERATION
 The non-absorbable suture material (Mersilene) is placed as a
purse string suture, as high as possible (level of internal os)
 The suture starts at the anterior wall of the cervix. Taking
successive deep bites (4–5 sites) it is carried around the lateral
and posterior walls back to the anterior wall again where the
two ends of the suture are tied.
 Commonly performed method nowadays.
65

II. Modified Shirokdar Cerclage
 A transverse incision is made on the vaginal wall and the bladder
is pushed up to expose the level of the internal os.
 The non-absorbable suture material—Mersilene tape is passed
submucousaly with the help of any curved round bodied needle
so as to bring the suture ends to the posterior.
 The ends of the tapes are tied up posteriorly by a knot.
 The anterior incision is repaired using chromic catgut.
67

III. Transabdominal Cerclage
 Rarely done in cases of repeated failure of vaginal approach
 Cerclage is placed at the level of isthmus
 Delivery by CS
69

 Postoperative care:
 The patient should be in bed for at least 2–3 days
 Progesterone supplementation - Weekly injections of 17 α hydroxy
progesterone caproate 500 mg IM
 Patient is asked to avoid sexual inercourse
 Removal of stitch:
 The stitch should be removed at 37th week, or earlier if labor pain
starts or features of abortion appear.
 If the stitch is not cut in time, uterine rupture or cervical tear may
occur.
70

 Complications:
 Slipping or cutting through the suture
 Chorioamnionitis
 Rupture of the membranes
 Cervical scarring and dystocia requiring cesarean delivery.
71

 The overall risk of recurrent miscarriage is about 25–30%
irrespective of the number of previous spontaneous miscarriage.
 The overall prognosis is good even without therapy.
 The chance of successful pregnancy is about 70–80% with an
effective therapy.
72

 This refers to the deliberate termination of pregnancy.
 Termination of pregnancy is requested for and done for reasons
permissible by law either through a surgical procedure or by
pharmacological means.
 Under the current provisions for Ghana, an induced abortion
may be carried out legally only under the following conditions:
 in case of rape, defilement or incest;
 threat to the physical and mental health of the mother;
 presence of foetal abnormality and mental retardation of the
mother.
74

 FBC
 Blood group and Rhesus factor
 Special Investigations for medico-legal indications e.g. rape
(DNA, HIV status etc.)
75

 To ensure that legal requirements for termination are met
 To ensure safe abortion
 To provide family planning counselling and services as needed
 To prevent risk of Rhesus incompatibility in future pregnancies
 Non-pharmacological treatment
 Manual Vacuum Aspiration (4-12 week gestation)
 Dilatation and curettage (4-12 week gestation)
 Cervical ripening followed by Dilatation and Evacuation (D&E) (>
12 weeks gestation)
76

 A. Medication Abortion Evidence Rating: [A]
 Mifepristone
 Then
 Misoprostol
77

GESTATIONAL AGE Mifepristone and
Misoprostol
(Evidence Rating A)
Misoprostol Only
(Evidence Rating A)
4- 8 weeks Mifepristone 200 mg
stat.
Followed 24-48 hours
later by Misoprostol,
800 micrograms (oral,
vaginally) stat followed
if needed by 2 repeat
doses of 800
micrograms vaginally
or sublingually every 3-
12 hourly (max. 3
doses)
Misoprostol only: 800
microgram stat.
vaginally followed by 2
repeat doses of 800
microgram vaginally or
sublingually if needed
every 3-12 hourly
(max. 3 doses)
78

orally, 36 -48 hours
later:
Misoprostol 800
microgram vaginally,
follow with up to 2
additional doses of
Misoprostol 400
microgram sublingually
or vaginally at 3 -12
hour intervals (max. 3
doses)
Misoprostol 800
microgram vaginally
stat.,
Followed by 2 repeat
doses of 800
microgram every 3-12
hours if needed (max.
3 doses)
79

orally, PLUS 36-48
hours later
Misoprostol 800
microgram vaginally,
Follow by repeated
dose of Misoprostol 400
microgram every 3-4
hourly vaginally (or
sublingually if there is
significant bleeding
from earlier vaginal
misoprostol
administration) until
expulsion.
(max. 5 doses)
Misoprostol 800
microgram vaginally
followed by 400
microgram vaginally
(or sublingually if
there is significant
bleeding) at 3-6 hourly
intervals.
Repeat dosing until
expulsion
(max. 5 doses)
80

orally, PLUS 36-48
hours later
Misoprostol 100- 200
orally every 4 hours
Repeat dosing until
expulsion (max. 5
doses. Decrease dose
of misoprostol with
increasing gestational
age.
Misoprostol 100-200
orally every 4 hours
Repeat dosing until
expulsion (max. 5
doses.
Decrease dose of
misoprostol with
increasing gestational
age.
81

83
Patient Initials ML Sex F Age 22 years
Date 17/5/2021 Height 1.5m Weight 54kg
BMI 22kg/m2
Ward G3 (Gynecology)

 Intermittent bleeding per vagina for 3 weeks; severe
intermittent lower abdominal pain
84

 Patient was in her usual state of health until three weeks prior
to presentation: she had an USG taken at a private facility which
indicated she was pregnant.
 She took some medication (name unknown, orally) to
terminated the pregnancy. She started bleeding PV (per vagina)
some few hours after.
 Bleeding initially was mild (one pad a day, moderately soaked
with no clots), but gradually became heavy (3 pads per day very
soaked with large clots) and associated intermittent lower
abdominal pain (LAP).
 She expelled the fetus this afternoon without the placenta
prompting her to report to this facility for management.
85

 Patient is single;
 unemployed;
 lives in Lekpleve;
 does not smoke cigarette nor drink alcohol;
 not insured;
 and is a Christian
86

 No history of:
 hypertension,
 diabetes mellitus,
 sickle cell disease,
 asthma
87

 No history of:
 hospital admission,
 hemotransfusion,
 surgery,
 hypertension,
 diabetes mellitus,
 sickle cell disease,
 asthma nor
 peptic ulcer disease
88

 Temperature- 35.4oC
 Blood pressure- 100/70mmHg
 Pulse- 102bpm
 Respiratory rate-22cpm
89

 G1 P0 + 1IA (induced abortions)
 G1 (2017), induced at 8 weeks, no post-abortion complication
 Currently G2 P0 + 2IA
90

 Menarche:15yrs
 Cycle: 30/5 menorrhea, dysmenorrhea-, intermenstrual
bleeding-
 Coitarche: 15yrs
 Lifetime partners: 2
 Breast examination: No
 Cervical cancer screening: No
 Formal contraception: No
91

Parameter Reference Range Dates
11/5/2021 Flag
WBC 4.4–11.3 x 103/uL 8.4 N
RBC 4.1–5.1 × 106/uL 2.84 L
HBG 12.3–15.3 g/dL 8.1 L
HCT 36–45 % 37 N
MCV 80–96 fL 86 N
MCH 27–33 pg 29 N
MCHC 33.4–35.5 g/dL 34 H
PLT 150- 450 x
103/uL
243 N
NEUT 4.5- 7.3 x 103/uL 5.3 N
92

Parameter Reference Range Dates
18/3/2021 Flag
NEUT% 45- 73 % 55.5 N
LYMPH 2-4 x 103/uL 3.56 N
LYMPH% 20–40 % 6.4 N
MONO 0.2-0.8 x 103/uL 0.58 N
MONO% 2–8% 6.9 N
EO 0.0- 0.04 x
103/uL
0.03 N
EO% 0- 4% 0.7 N
BASO 0.0- 0.01 x
103/uL
0.0 N
BASO% 0- 1% 0.5 N 94

 Speculum exam - vagina stained with bright red blood with
clots, cervical os about 4cm dilated
95

Medication
[name/
strength
Route]
Dosage
/Frequency
Start Date End Date Reason for
use
Comment
IV
Metronidazole
500mg
500mg stat 17/5/2021 17/5/2021 Antibiotic
prohylaxis for
uterine
evacuation
and post-
uterine
evacuation
Appropriate
IV
Ciprofloxacin
400mg
400mg BD 17/5/2021 17/5/2021 Antibiotic
prohylaxis for
uterine
evacuation
and post-
uterine
evacuation
Appropriate
IV Normal
Saline 500ml
1000ml OD 17/5/2021 17/5/2021 For fluid
replacement
therapy
Appropriate
IV
Hydrocortison
e 100mg
100mg stat 17/5/2021 17/5/2021 For
prophylaxis
against
transfusion-
induced
allergic
reaction
Appropriate
96

Medication
[name/ strength
Route]
Dosage
/Frequency
Start Date End Date Reason for use Comment
IV Promethazine
25mg
25mg stat 17/5/2021 17/5/2021 For prophylaxis
against opioid-
induced nausea
and vomiting
Appropriate
IM Pethidine
100mg
100mg stat 17/5/2021 17/5/2021 For anaesthesia Appropriate
Tab
Metronidazole
400mg
400mg TDS 17/5/2021 26/5/2021 For prophylaxis
against post-
uterine
evacuation
infection
Inappropriate
duration of
therapy
Tab
Ciprofloxacin
500mg
500mg BD 17/5/2021 26/5/2021 For prophylaxis
against post-
uterine
evacuation
infection
Appropriate
Tab Doxycycline
100mg
100mg BD 17/5/2021 26/5/2021 For prophylaxis
against post-
uterine
evacuation
infection
Inappropriate
duration of
therapy
97

Medication
[name/
strength
Route]
Dosage
/Frequency
Start Date End Date Reason for
use
Comment
Supp
Diclofenac
100mg
100mg OD 17/5/2021 23/5/2021 For analgesia Appropriate
Whole Blood 1
Unit
I unit 17/5/2021 17/5/2021 For the
management
of anemia
Appropriate
Tab
Misoprostol
(Intravaginal)
200mcg
800mcg stat 17/5/2021 17/5/2021 For induction
of labour
Inappropriate
dose
Tab vitamin C
100mg
100mg TDS 18/5/2021 16/6/2021 For wound
healing
Appropriate
Supp
Diclofenac
100mg
100mg OD 17/5/2021 23/5/2021 For analgesia Appropriate
98

 Prolonged duration of post- uterine evacuation antibiotic
prophylaxis (Tab metronidazole; Tab Doxycycline)
 Inappropriate dose of misoprostol.
 Untreated Anemia
100

Medication [name/
strength Route]
Dosage
/Frequency
Duration of
therapy
Reason for use
Tab Metronidazole
400mg
400mg TDS 10 days For prophylaxis
against post-
uterine evacuation
infection
Tab Ciprofloxacin
500mg
500mg BD 10 days For prophylaxis
against post-
uterine evacuation
infection
Tab Doxycycline
100mg
100mg BD 10 days For prophylaxis
against post-
uterine evacuation
infection
Supp Diclofenac
100mg
100mg OD 7 days For analgesia
Tab vitamin C
100mg
100mg TDS 30 days To promote uterine
wound healing 101

 SUBJECTIVE DATA
 Intermittent bleeding per vagina for 3 weeks; severe
intermittent lower abdominal pain

 OBJECTIVE DATA:
 Vagina stained with bright red blood with clots, cervical os
about 4cm dilated; uterus about 16 weeks; formed placenta
103

 An abortion is defined as a spontaneous termination of a
pregnancy before it reaches viability (Cunningham, 2018).
 The World Health Organization also defines abortion as
pregnancy termination or loss before 20 weeks' gestation or with
a fetus delivered weighing < 500 g.
 According to the 2017 Ghana Standard Treatment Guidelines
(STG), Abortion is defined as expulsion of the fetus and products
of conception before the 28th week of gestation (STG, 2017).
104

 Clinically, spontaneous abortion can be classified as complete,
incomplete, missed or threatened.
 It may be complicated by profuse bleeding or by an infection
(septic abortion) (Cunningham, 2018; STG, 2017).
 Induced abortion on the other hand can be classified as either
therapeutic or criminal (STG, 2017).
 Before 10 weeks of gestation, the fetus and placenta are
delivered together.
 After this gestation age, fetus and placenta are delivered
separately.
 Tissue may remain in the uterus or extrude from the cervical os.
 This is an incomplete abortion (Cunningham, 2018).
105

 Symptoms of an abortion include: passage of large blood clots
and/or the foetus and some products per vaginam; severe lower
abdominal pain (STG, 2017).
 Signs may also include severe bleeding: pallor and/or shock
(collapsed peripheral vessels, fast pulse, falling BP and cold
clammy skin); uterine size smaller than the dates; dilated cervix
with already aborted fetus; whole placenta or parts thereof may
be present within the uterine cavity (STG, 2017).
 Speculum examination on ML revealed: vagina stained with
bright red blood with clots, cervical os about 4cm dilated. A
uterus evacuation revealed formed placenta.
 The subjective and objective data confirm the diagnosis.
106

 An incomplete abortion can be managed in three ways:
expectant management, medical management with misoprostol
(prostaglandin E1) or by curettage.
 Expectant management has been shown in randomized trials to
have a failure rate of 25 percent (Nadarajah, 2014; Nielsen,
1999; Trinder, 2006).
 Curettage, has a success rate of 95 to 100 percent and it is not
usually used due to its invasive nature.
107

 Metronidazole is effective against anaerobes such as Clostridium spp,
Bacteroides, and some Streptococci. Micro- organisms implicated in septic
abortion generally arise from normal vaginal flora (Daif, 2009).
 These include, Group A Streptococci (example S. pyogens), Clostridium
perfringens and Clostridium sordelli. Particularly worrisome in necrotizing
infections and toxic shock syndrome is Group A Streptococci- S. pyogens)
(Daif, 2009).
 Deaths have been reported from toxic shock syndrome due to Clostridium
perfringens (Centers for Disease Control and Prevention, 2005).
 Similar infections are caused by Clostridium sordellii and have clinical
manifestations that begin within a few days after an abortion.
 Women may be afebrile when first seen with severe endothelial injury,
hemoconcentration, capillary leakage, a profound leucocytosis and
hypotension. Administration of broad spectrum antibiotics is essential in the
management of an abortion complicated by an infection.
108

 Organism generally implicated in female genital infections
include Gram-positive cocci- group A, B, and D streptococci,
enterococcus, Staphylococcus epidermidis, Staphylococcus
aureus; Gram- negative bacteria- Escherichia coli, Proteus,
Klebsiella; Gram- variable- Gardnerella vaginalis; Neisseria
gonorrhoeae and Chlamydia, Mycoplasma; Anaerobes- cocci-
Peptococcus species and Peptostreptococcus, others-
Bacteroides, Clostridium, Mobiluncus and Fusobacterium.
109

 No rigorous studies have evaluated providing prophylaxis
following operative vaginal delivery or manual removal of the
placenta (Chongsomchai, 2014; Liabsuetrakul, 2017).
 However, antibiotic prophylaxis has been shown to reduce post-
procedural infection rates.
 Metronidazole is a suitable agent in antibiotic prophylaxis in ML
for uterus evacuation and for post- uterus evacuation.
 This drug inhibits protein synthesis by interacting with DNA and
causing a loss of helical DNA structure and strand breakage
(Weir, 2021).
110

 To prevent infections after uterus evacuation the STG recommends
Tab 400mg metronidazole, 8 hourly for 5- 7 days: in combination
with a broad spectrum antibiotic (STG, 2017).
 Metronidazole can also be used for prophylaxis before uterus
evacuation as IV: 500 mg within one hour before procedure, in
combination with another antibiotic (Weir, 2021).
 The dosage, route, frequency and duration for metronidazole for
prophylaxis against infection before uterus evacuation is
appropriate.
 The dosage, route and frequency for metronidazole for prophylaxis
against infection after uterus evacuation is appropriate. However,
the duration of therapy is longer than required (STG, 2017; Savaris,
2011). [Follow-up oral antibiotic treatment is likely unnecessary
(Savaris, 2011)]. This is buttressed by the fact patient has normal
WBCs values 8.4 103/uL
111

 Ciprofloxacin is a fluoroquinolone. It exerts its bactericidal
effect by inhibiting bacterial DNA synthesis via inhibition of
topoisomerase IV in gram- positive bacteria and DNA gyrase in
gram- negative bacteria.
 Ciprofloxacin is a broad spectrum antibiotic and is exceptionally
active against gram- negative enteric coliforms and
Pseudomonas aeruginosa.
112

 Micro- organisms implicated in septic abortion generally arise from
normal vaginal flora (Daif, 2009).
 These include, Group A Streptococci (example S. pyogens),
Clostridium perfringens and Clostridium sordelli. Particularly
worrisome in necrotizing infections and toxic shock syndrome is
Group A Streptococci- S. pyogens) (Daif, 2009).
 Deaths have been reported from toxic shock syndrome due to
Clostridium perfringens (Centers for Disease Control and
Prevention, 2005). Similar infections are caused by Clostridium
sordellii and have clinical manifestations that begin within a few
days after an abortion.
 Women may be afebrile when first seen with severe endothelial
injury, hemoconcentration, capillary leakage, a profound
leucocytosis and hypotension. Administration of broad spectrum
antibiotics is essential in the management of an abortion
complicated by an infection.
113

 Organism generally implicated in female genital infections
include Gram-positive cocci- group A, B, and D streptococci,
enterococcus, Staphylococcus epidermidis, Staphylococcus
aureus; Gram- negative bacteria- Escherichia coli, Proteus,
Klebsiella; Gram- variable- Gardnerella vaginalis; Neisseria
gonorrhoeae and Chlamydia, Mycoplasma; Anaerobes- cocci-
Peptococcus species and Peptostreptococcus, others-
Bacteroides, Clostridium, Mobiluncus and Fusobacterium.
 No rigorous studies have evaluated providing prophylaxis
following operative vaginal delivery or manual removal of the
placenta (Chongsomchai, 2014; Liabsuetrakul, 2017).
 However, antibiotic prophylaxis has been shown to reduce post-
procedural infection rates
114

 To prevent infections after uterus evacuation the STG
recommends Tab 400mg metronidazole, 8 hourly for 5- 7 days: in
combination with a broad spectrum antibiotic (STG, 2017).
 Metronidazole can also be used for prophylaxis before uterus
evacuation at as IV: 500 mg within one hour before procedure,
in combination with another antibiotic (Weir, 2021).
 Addition of ciprofloxacin to metronidazole extends antibiotic
coverage to reduce infections after evacuation.
 After oral administration, ciprofloxacin is 70% to 80%
bioavailable and reaches peak concentration within 1 to 2 hours
(Pharmaceutical Press, 2014).
 For antibiotic prophylaxis, ciprofloxacin should be administered
as IV: 400mg 8- 12 hourly (administered over 60 minutes) (STG,
2017). As oral prophylaxis BNF 76 recommends 500mg BD (BNF
76, 2018)
 The dosage regimen for both IV and oral ciprofloxacin is
appropriate
115

 Hydrocortisone is a corticosteroid and functions by inhibiting
phospholipase A2 needed for the conversion of membrane
phospholipids to arachidonic acid (Waller, 2018).
 They decrease the migration of polymorphonuclear leukocytes
and reverse capillary permeability (Wanner, 2020).
 Corticosteroids show limited effects in the initial stages of
anaphylactic reactions but are useful in the presence of
persistent hypotension and bronchospasm (Wanner, 2020).
 The use of hydrocortisone has a limited role in patient’s allergic
reaction but offers some benefits.
 The dosage regimen is appropriate (BNF 76, 2018).
116

 Blood transfusion is administering blood components or whole blood
intravenously to a patient.
 Indications for a transfusion include: haemorrhage due to surgery or
injury; illness that prevents body from making blood or some of its
components.
 1 unit of whole blood contains 450 mL whole blood in 63 mL
anticoagulant‐preservative solution of which Hb will be
approximately 1.2 g/dL and haematocrit (Hct) 35‐45% with no
functional platelets or labile coagulation factors (V and VIII) when
stored at +2°C to +6°C.
 Transfusion must be completed within 4 hours of commencement
 Post- transfusion hemoglobin was 7g/dl, patient was without
symptoms of anemia
 The blood product and dosage regimen were appropriate.
117

 SYR BIOFERON 5ml BD x 30/7 should be added to patients
therapy to treat anemia
 Syr bioferon contains ferric ammonium citrate 20mg, folic acid
and vitamin B12.
 Folic acid and vitamin B12 deficiency are implicated in
megaloblastic anemia. Both are needed for DNA synthesis.
 In megaloblastic anemia due to folic acid deficiency, through
folate replacement: RBC morphology should return within 24 to
48 hours. Hypersegmented neutrophils should be cleared in 1
week. Serum studies and hemogram should normalize in 10
days. Retic count should increase by day 2 to day 3 and peak by
day 10. Anemia should be corrected by 1 to 2 months.
 In iron replacement therapy, retic count begins to rise by 3rd and
4th day, peaks by 7th and 10th day and begins to fall by second
week. HGB is expected to rise by 1 to 2 g/dl within 2 to 3
weeks. And HCT is expected to rise by 6 % within 2 to 3 weeks
118

 Vitamin C is needed for the synthesis of collagen, L- carnitine
and some neurotransmitter.
 It is also vital in protein metabolism.
 Collagen is a primal component of connective tissue which is
involved in wound healing. Vitamin C is also a physiological
antioxidant and regenerates other antioxidants in the body, such
as alpha- tocopherol. Vitamin C is also essential in immune
function and needed in the absorption of non-heme iron from
food.
 The vitamin C dosage regimen was appropriately prescribed.
119

 Pethidine is an opioid analgesic that exerts its effect via the mu
opioid receptors.
 The active metabolite is normeperidine. According to Balkan et
al, pain is managed based on the severity of pain.
 This can be done using a verbal scale.
 In the verbal scale, parameters used are: no pain, mild,
moderate and severe pain.
 This patient’s has been appropriate classified as severe due to
his surgery.
120

 Diclofenac is non- steroidal anti- inflammatory drug that works by
blocking the release of inflammatory mediators that cause fever
pain and inflammation.
 Diclofenac has been shown to be effective in postoperative pain
management and reducing postoperative antibiotic demands
(Bakhista, 2016)
 The use of this medication is appropriate in this patient because
she is experiencing pain after caesarean section.
 The route of administration is appropriate in this patient. Lim N. L.
et al, (2001) showed that a single dose of diclofenac 100mg
suppository is effective in reducing post caesarean opioid
requirements by 33% for the first 24 hours post operatively.
 The dosage regimen is appropriate.
121

 It contains sodium and chloride at concentrations of 154mEq/L
each.
 It has an osmolality of 308 mOsm/L and gives no calories (Lee,
2017).
 Normal saline is the isotonic solution of choice for expanding the
extracellular fluid volume because it does not enter the
intracellular compartment. It is administered to correct
extracellular fluid volume deficit because it remains within the ECF
(Lee, 2017).
 ML presented with a history of 3 weeks of intermittent bleed per
vaginam (3 soaked pads per day).
 Normal saline should be used for fluid resuscitation where
appropriate (STG, 2017)
 Patient qualifies for normal saline therapy.
 The dosage regimen is appropriate (STG, 2017)
122

 Broad spectrum antibiotics which inhibits bacterial protein
synthesis by binding to the 30s ribosomal unit (Waller, 2018).
 Indications: chlamydia, pneumonia, acute exacerbation of
COPD, mild diabetic foot infection, cellulitis, acne, malaria
prophylaxis, Syphilis (Waller, 2018)
 It has a broad spectrum of activity and effective against gram-
positive and gram- negative, aerobic and anaerobic bacteria,
spirochetes and mycoplasma.
 To prevent post- abortal infection after a first- or second-
trimester surgical evacuation, prophylactic doxycycline, 100 mg
orally 1 hour before and then 200 mg orally after, is provided
(Achilles, 2011 ; American College of Obstetricians and
Gynecologists, 2016).
123

 Among the antibiotics recommended by the STG in infection
prevention after uterus evacuation are amoxicillin, oral, 500 mg 8
hourly for 5-7days and metronidazole, oral, 400 mg 8 hourly for 5-
7days (STG).
 Doxycycline is a suitable choice however if Chlamydia trachomatis
is indicated (STG, 2017; Cunningham, 2018)
 No screening for Chlamydia has been done for patient.
 Doxycycline should still be used based on patient’s obstetric and
gynaecology history.
 According to STG 2017, treatment of Chlamydia infections with
Doxycycline should be administered as follows:
 Doxycycline, oral, 100 mg 12 hourly for 7 days
 The duration of therapy for doxycycline should does be reduced to
7 days.
124

 Promethazine, a phenothiazine derivative, is a sedating
antihistamine with antimuscarinic, significant sedative, and
some serotonin-antagonist properties.
 Promethazine hydrochloride is given parenterally by deep
intramuscular injection as a solution of 25 or 50 mg/mL. It may
also be given by slow intravenous injection or injected into the
tubing of a freely running infusion in a concentration of not
more than 25 mg/mL, although it is usually diluted to 2.5
mg/mL (Pharmaceutical Press, 2014).
 The rate of infusion should not exceed 25 mg/minute
(Pharmaceutical Press, 2014).
125

 The usual parenteral dose for all indications apart from nausea
and vomiting is 25 to 50 mg; a dose of IOO mg should not be
exceeded.
 Doses of 12.5 to 25 mg, repeated at intervals of not less than 4
hours, may be given for the treatment of nausea and vomiting,
although not more than I00 mg is usually given in 24 hours.
 In this case, promethazine is being used to prevent pethidine-
induced nausea and vomiting.
 IV promethazine is appropriate in this patient.
 The dosage regimen is also appropriate
126

 An incomplete abortion can be managed in three ways:
expectant management, medical management with misoprostol
(prostaglandin E1) or by curettage.
 Expectant management has been shown in randomized trials to
have a failure rate of 25 percent (Nadarajah, 2014; Nielsen,
1999; Trinder, 2006). Curettage, has a success rate of 95 to 100
percent and it is not usually used due to its invasive nature.
 According to STG, 2017, for uterus evacuation in incomplete
abortion with uterine size > 12 weeks and ≤ 24 weeks
Evidence Rating: [A]
 Misoprostol, oral, 600 micrograms stat. Or
127

 Misoprostol, 200- 600 mg orally or 400- 800mg vaginally,
buccally, or sublingually can be used in first trimester medical
abortion (Cunningham, 2018). The oral route being associated
with more side effects.
 With evidence A rating in medical abortion of fetus of
gestational age, 13 to 24 weeks, STG, 2017 recommends:
 Misoprostol 800 microgram vaginally followed by 400 microgram
vaginally (or sublingually if there is significant bleeding) at 3-6
hourly intervals (STG, 2017).
 A high dose of misoprostol of 800mcg vaginally was not
warranted in this patient. 600mcg stat orally would have
sufficed.
 The dose and route of misoprostol are inappropriate..
128

 GOALS OF THERAPY
 To resuscitate patient
 To evacuate the retained products of conception from the uterus
 To prevent infection with antibiotic prophylaxis
 To determine cause of abortion, if recurrent
129

 CONTINUE
 Tab ciprofloxacin 500mg BD for 10 days
 Supp Diclofenac 100mg OD for 7 days
 Tab vitamin C 100mg TDS for 30 days
 RECOMMENDATIONS
 Tab 400mg metronidazole, 8 hourly for 7 days
 Syr bioferon 5ml bd x 30/7
130

DRUG EFFICACY TOXICITY
IV/ Oral Metronidazole
500mg
Absence of infection Asthenia, diarrhea,
hypotension
(<90/60mmHg)
IV/ Oral Ciprofloxacin
400mg
Absence of infection Constipation; asthenia;
joint pain; dyspnoea;
fever- > 37.5;
vomiting; skin
reactions.
IV Normal Saline 500ml Satisfactory hydration
status
Edema;
Hypernatremia;
Hyperchloremia;
Acute kidney injury
IV Hydrocortisone 100mg Absence of blood
transfusion- associated
pruritus
Hiccups,
exophthalmos,
lipomatosis 131

Supp Diclofenac 100mg Resolution of lower
abdominal pain
Diarrhoea, headache,
rash
Whole Blood 1 Unit Rise in Hb by 1g/dL Transfusion reactions
Tab Misoprostol
(Intravaginal) 200mcg
Delivery of birth products Nausea, vomiting
Tab vitamin C 100mg Improved general
wellbeing; uterine wound
healing (resolution of
lower abdominal pain)
Diarrhea, polyuria
132

IV Promethazine 25mg Absence of nausea and
vomiting
Fatigue, epigastric
discomfort, skin
reactions, hemolytic
anemia, decreased
appetite, Arrhythmias;
pulse > 100bpm
IM Pethidine 100mg Absence of pain during
evacuation of uterus
Arrhythmias; pulse >
100bpm; confusion;
constipation; euphoric
mood; hallucinations
Tab doxycycline 100mg Absence of infection Nausea, vomiting,
angioedema, skin
reactions, diarrhea,
headache.
133

 Patient was counselled on the need to adhere to medication
therapy
 Patient was counselled on the potential side effects of
medications
 Advised to stop taking supp. Diclofenac on the appearance of a skin
rash and report to the hospital
 Patient was counselled on family planning methods
 Patient was counselled on the dangers of a criminal abortion.
134

 Afebrile (temperature- 36.5C)
 Uterus successfully evacuated
 Hydration status satisfactory
 Post transfusion Hb, 7g/dL
 Recommendations were accepted and implemented.
135

 The pharmacist made the following recommendations:
 Tab 400mg metronidazole, 8 hourly for 7 days
 Syr bioferon 5ml bd x 30/7
 The pharmacist counselled the patient on the following:
 the need to adhere to medication therapy
 the potential side effects of medications
 Advised to stop taking supp. Diclofenac on the appearance of a skin rash
and report to the hospital
 on family planning methods
 on the dangers of a criminal abortion
136

 American College o f Obstetricians and Gynecologists: Misoprostol
for postabortion care. Committee Opinion No. 427, February 2009
 American College of Obstetricians and Gynecologists: Abortion
policy. College Statement of Policy. January 1 993, Reaffirmed 20 1
4a
 American College of Obstetricians and Gynecologists: Induced
abortion. In Guidelines for Women's Health Care, 4th ed.
Washington, 2014b
 American College of Obstetricians and Gynecologists: Antibiotic
prophylaxis for gynecologic procedures. Practice Bulletin No. 104,
May 2009, Reaffirmed 2016a
 Cunningham et al (2018). Williams Obstetrics. 25th Edition. McGraw-
Hill Education, USA. Pages 346- 364.
137

 DaifJL, Levie M, Chudnof S, e t al: Group A streptococcus causing
necrotizing fasciitis and toxic shock syndrome after medical
termination of pregnancy. Obstet Gynecol 113 (2Pt2): 504, 2009
 Fox MC, Krajewski CM: Cervical preparation for second-trimester
surgical abortion prior to 20 weeks' gestation: SFP Guideline #20 13-
4. Contraception 89 (2) :75, 2014
 Gawron LM, Hammond C, Ernst LM: Perinatal pathologic
examination of non intact, second-trimester fetal demise
specimens: the value of standardization. Arch Pathol Lab Med 1
37(8) : 1083, 2013
 Luise C , Jermy K , May C , e t al: Outcome of expectant
management o f spontaneous first trimester miscarriage:
observational study. BvlJ 324: 873, 2002
 Lykke JA, Dideriksen L, Lidegaard 0, et al: First-trimester vaginal
bleeding and complications later in pregnancy. Obstet Gynecol 1 1
5:935, 2010
138

 MacIsaac L, Darney P : Early surgical abortion: a n altenative to
and backup for medical abortion. Am J Obstet Gynecol 1 83 :
S76, 2000
 MacIsaac L, Grossman 0, Balistreri E, et al: A randomized
controlled trial of laminaria, oral misoprostol, and vaginal
misoprostol before abortion. Obstet Gynecol 93(5 Pt 1 ) :766, 1
999
 Ministry Of Health (2017). Standard Treatment Guidelines.
Seventh Edition. Yamens Press Limited, Accra. Pages 359- 370
139

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