The document provides an outline and overview of abortion. It defines abortion and discusses the epidemiology, classification, etiologies, diagnosis, complications and management of abortion. It summarizes the different clinical types of abortion such as threatened, inevitable, incomplete, complete and missed abortion. It also discusses the diagnosis, risk factors, complications and diagnostic workup of abortion. Finally, it discusses abortion laws in Ethiopia.

1. Lecture on Abortion
Dr.Ashenafi D.(MD)
Email : Ashenafidessalegn8@gmail.com

2. Outline
Define abortion.
Epidemiology of abortion.
Introduction
Classification of abortion.
Etiologies of spontaneous abortion.
Diagnosis of abortion.
complications of abortion.
Management of abortion.

3. Definition of abortion
• Abortion (miscarriage) is termination of
pregnancy prior to completion of the 28th
gestational week.
• It also implies delivery of all or any part of
the products of conception, with or without a
fetus weighing less than 1000g.
• WHO considers a gestational age of 20
weeks and wt less than 500 g as the cut off
point.

4. 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 .

5. Introduction
Is the commonest gynecological & obstetric
disorder.
• About 15% of clinically recognized
pregnancies end in abortion.
• 60% of chemically evident pregnancies end
in spontaneous abortion.
• Most abortions (80%) occur before 12
weeks of pregnancy.
The majority of deaths from abortion result

6. Classification of abortion
A. Clinically
1. Threatened abortion
2. Inevitable abortion
3. Incomplete abortion
4. Complete abortion
5. Missed abortion
6. Septic abortion
7. Recurrent abortion

7. B. Gestational Age
1. Fist trimester
2. Second trimester
C. Method
1. Spontaneous-if it occurs with no
intervention
2. Induced-safe
-unsafe

8. Etiology
A. First trimester abortion
1. Fetal chromosomal abnormalities
• is the commonest cause of abortion
• 50– 70 % of the first trimester abortions are
due to chromosomal abnormalities
• Polyploidy, usually in the form of triploidy, is
found in approximately 20% of all
miscarriages.
2. An embryonic pregnancy - Blighted ovum

9. 4.Parental balanced translocation
5. Infections
genital tract infection , systemic infection
with pyrexia & TORCH syndrome
6.Endocrine disorders
Diabetes, thyroid disorders , PCOS &
Corpus luteum insufficiency
7. Uterine disorders
Uterine anomalies , sub mucus fibroid &
Asherman's syndrome

10. 8. Thrombophilia: Congenital deficiency of
protein C & S, & anti-thrombin III
9. Immunological disorders : Anti
phospholipid syndrome and SLE
10.Cigarette smoking & chemical agents
11.Psychological disorders

11. B. Secondtrimester abortion
1. Multiple pregnancy
2. Cervical incompetence (congenital &
acquired )
3. Uterine anomalies and sub mucous fibroid
4. Genital tract infection and PROM
5. Systemic infections: HIV, Malaria, syphilis,
Rubella
6. Maternal health: Diabetes, Renal disease,

12. Spontaneous abortion
 An abortion is said to be spontaneous if it
occurs with no intervention. Incidence of
spontaneous abortion is between 10% and
20% of all pregnancies.
 It is most commonly due to fetal
chromosomal defects such as;
• Trisomies
• Monosomies &
• Polyploidy
 This usually occurs during the first trimester.

13. Induced abortion
An abortion is said to be induced if it
results from medical or surgical
intervention that can cause abortion.
It could be Safe or Unsafe abortion.

14. Safe abortion
Safe abortion- is termination of
unwanted pregnancy by a qualified
person, with proper equipment, correct
technique & under sanitary standards.
Therapeutic abortion- Subset of safe
abortion aimed to interrupt pregnancy to:
save the life of the pregnant woman
preserve the woman's physical or mental
health
terminate pregnancy with fatal congenital

15. Unsafe abortion-the termination of unwanted pregnancy either by a
person who doesn’t have the skills or in an environment
lacking the minimal medical standards or both.
 Health consequences of unsafe abortion:
 Bleeding
 Infection
 Perforation of the uterus, intestine & other
internal organs
 Chronic pelvic pain
 Infertility
 Death

16. Clinical types of abortion
 Threatened abortion
Minimal vaginal bleeding and lower abdominal
cramps
with or without uterine contractions and
without cervical dilatation and without expulsion of the
products of conception.
The fetus is alive(60-80% continue the pregnancy)
 Inevitable abortion
Heavier vaginal bleeding and more severe cramps
with dilatation of the cervix but without expulsion of
the products of conception
Leakage of liquor even without open cervix

17. Incomplete abortion
is a clinical condition in which
vaginal bleeding continues and
cervix remains open despite
expulsion of part of the products of
conception.
Complete abortion
Complete expulsion of all
conceptus parts
Uterus well contracted and cervix
closed

18. Missed abortion
the fetus dies in utero and is retained for at
least four weeks
There is usually history of threatened
abortion preceding it.
Pregnancy symptoms disappear
Cessation of fetal movement is reported(if it
occurs >18wks)
Failure of uterine growth results in small for
gestational age uterus.

19.  Septic (infected) abortion
Xized by offensive vaginal discharge
Temp>380C & lower abd.pain or tenderness
Majority follow unsafely induced abortions.
It eventually results in death by causing septic
shock.

20. Recurrent(habitual) abortion
occurrence of three or more consecutive
spontaneous abortions.
• Idiopathic in 50% of the cases ,known causes
include
1. Chromosomal disorders:
 Fetal chromosomal abnormalities & structural
abnormalities
 Parental balanced translocation
2. Anatomical disorders:
 Cervical incompetence: →congenital and acquired
 Uterine causes: → sub mucous fibroids, uterine anomalies &

21. 3.Medical disorders
 Endocrine disorders : diabetes , thyroid
disorders , PCOS & corpus luteum insufficiency
.
 Immunological disorders : Anticardiolipin
syndrome & SLE.
 Thrombophilia: congenital deficiency of Protein
C&S and antithrombin III, & presence of factor V
leiden.
 Infections
 TORCH - CMV may be a cause of recurrent
abortion, but TORCH are not causes of recurrent
abortion.

22. Clinical pictures
Threatened Abortion
 Slight or mild, bright red vaginal
bleeding originating from the
choriodecidual interface
 Slight or absent pain
 Closed Cervix
 Pregnancy test is positive.
 Ultrasonography shows a living fetus

23. Inevitable Abortion
Vaginal bleeding is excessive and may
accompanied with clots.
Colicky Pain felt in the suprapubic region
radiating to the back
The internal os of the cervix is dilated and
products of conception may be felt through it
Rupture of membranes between 12-28
weeks is a sign of the inevitability of abortion

24.  Incomplete Abortion
The patient usually noticed the passage of a
part of the conception products
Bleeding is continuous.
On examination, the uterus is less than the
period of amenorrhea but still large in size.
The cervix is opened and retained contents
may be felt through it.
Ultrasonography: shows the retained
contents.

25. Complete Abortion
The bleeding is slight and gradually
diminishes
The pain Stops
The cervix is closed.
The uterus is slightly larger than
normal
Ultrasound : shows empty uterine

26. Missed Abortion
Regression of pregnancy symptoms as
nausea, vomiting and breast symptoms
The abdomen does not increase and may
even decrease in size
The fetal movements are not felt or ceases if
previously present
 Milk secretion may start particularly in
second trimester abortion because of the
decline in estrogens secretion

27. Diagnosis of Abortion
 Diagnosis of a pregnancy less than fetal viability
 Symptoms
 Vaginal bleeding
 Abdominal cramps
 Leakage of liquor or expulsion of conceptus tissue
 Regression of pregnancy symptoms in missed abortion
 Signs
 Hemodynamic instability
 Vaginal bleeding
 Cervical changes and reduced uterine size
 Visualization of expelled conceptus tissue
 Urine hCG –positive
 U/S- Gestational sac
- fetal pole/cardiac activity

28. Risk factors related to abortion mortality
 Age
 General state of health
 Gestational age
 Method of termination
 Technical competence
 Availability and accessibility of
facilities

29. Complications of Abortion
Heavy bleeding and shock
Uterine perforation
Infection and sepsis
Infertility later in life
Ectopic pregnancy later in life
Psychological trauma –
depression

30. Diagnostic workup of 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
FBS,VDRL,HBSAG

31. Management of Abortion
Depends on:
Clinical type of abortion
Gestational age: early versus late
Presence or absence of infection
General Measures
Secure IV line
Put on crystalloids
Analgesic
Uterotonic drugs
Prophylactic antibiotics

32. Choice of methods of termination
1. Medical termination
 Employed in very early (<7 to 9 weeks) and late
pregnancy terminations (≥ 15 weeks).
 Surgical methods are recommended for pregnancies
between these gestational ages.
2.Surgical termination
 The primary factors in choosing a particular surgical
technique are:
- volume & content of intrauterine tissue and
- the experience of the surgeon

35. Medical termination of 1st
trimester pregnancy
• Three medications for early medical abortion
have been widely studied and used:
1. the antiprogestin mifepristone
2. the antimetabolite methotrexate, and
3. the prostaglandin misoprostol
• These agents cause abortion by increasing
uterine contractility

36. Eligibility criteria for medical abortion
• Pregnancy up to 49 days of gestation
• Agreement to undergo surgical abortion if the
procedure fails
• Agreement to complete therapy and all clinic visits
• A means of reaching an emergency facility within
one hour if problems occur
• Legally competent to sign a consent form for
obtaining an abortion

37. Contraindications to medical abortion
• Pregnancy greater than 49 days
• Allergy to mifepristone or misoprostol
• Pregnancy with an IUD in place or obstruction of the
cervical canal (e.g., stenosis, leiomyoma)
• Ectopic pregnancy, GTD
• Chronic adrenal failure
• Severe asthma
• Longterm concurrent corticosteroid treatment
• Hemorrhagic disorder or use of anticoagulant drugs
• Inability to sign the consent agreement because of
lack of competence

38. Regimens for Medical Termination of
9-12 wks of GA
Mifepristone, 2oomg orally followed by:
Misoprostol, 800 mcg vaginally or
sublingually 36-48hours,repeat 4x every 3
hours
Misoprostol alone
800 mcg vaginally, repeated for up to
three doses

39. Regimens for Medical Termination of
>12 wks
1.Mifepristone/misoprostol
Mifepristone, 2oomg orally followed by:
Misoprostol, 800 mcg vaginally or
sublingually in 36-48hours,repeat 5x every
3 hours
2.Misoprostol alone
400 mcg vaginally, repeated for up to five
doses every 3 hours

40. Surgical termination of 1st trimester
pregnancy
1. Manual Vacuum Aspiration(MVA)
- safe & effective for GA < 12 weeks
- as safe & effective as EVA for GA < 10wks
- both MVA & EVA produce 60mmHg pressure
• Advantages of MVA over EVA:
- less pain and blood loss
- quieter/ no noise
- more portable, inexpensive, and
- does not require electricity,
=> a choice for low-resource settings

41. 2. Electric vacuum aspiration( EVA)
- Used for terminations at all GAs.
- A rigid curved suction curette/ cannula is used
- A metal curette may be used to verify completeness
3. Sharp curettage/ Dilatation and Curettage
- used in the absence of suction curettage equipments
Vacuum aspiration is preferable to sharp curettage
because:
- less pain and blood loss
- shorter duration of procedure & less skill
- less risk of uterine perforation or Asherman’s
syndrome

42. 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

43. 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
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

44. Components of Post abortion
care(PAC)
 Community service provider
partnership
 Counseling
 Emergency treatment of incomplete
abortion and its complications
 Post abortion family planning
services
 Linkage with other reproductive

45. Abortion law in Ethiopia
• The 1957 penal code allowed abortions only to
save the life or health of the woman.
• In 2004, the Ethiopian Parliament passed abortion
laws.
• Article 551 of the Penal Code of the FDRE
allows termination of pregnancy under the
following conditions:
1. Termination of pregnancy by a recognized
medical institution with in the period permitted by

46. a. The pregnancy is a result of rape or incest; or
b. The continuation of the pregnancy endangers the life of
the mother or the child or the health of the mother or where
the birth of the child is a risk to the life or health of the
mother; or
c. The fetus has an incurable and serious deformity; or
d. The pregnant woman, owing to a physical or mental
deficiency she suffers from or her minority, is physically
as well as mentally unfit to bring up the child.
2. In the case of grave and imminent danger which can be
averted only by an immediate intervention, an act of
terminating pregnancy in accordance with the provisions of
Article 75 of this Code is not punishable.